Soft Tissue and Surgical Site Infections

Brett Waibel, MD
Department of Surgery The Brody School of Medicine East Carolina University The Center of Excellence for Trauma and Surgical Critical Care Greenville, NC

Objectives
Soft Tissue Infections (STI) Bacteria Surgical Site Infections (SSI)

Soft Tissue Infections

Diverse group of diseases involving the skin and underlying structures

Soft Tissue Infections

Meleney Ulcer

Soft Tissue Infections

Classification
Superficial

Deep

Classification
Nonnecrotizing infections involve superficial structures generally Necrotizing infections involve deep structures generally

Symptoms
Range from subtle/nonspecific to obvious Common findings
Pain Edema Erythema Tenderness Warmth

Diagnosis
Host factors Environmental factors Specific clinical scenarios Host Factors Environmental Specific Scenarios COPD factors Bites
Cardiac Disease Cuts, lacerations Animal CHF Injection Human PVD sites Bites Chronic skin disease Diabetes Skin diseases Ulcers Steroids Water exposure Ulcers Immune Saltwater: V. vulnificus Compromise Surgical Incisions Freshwater: A. hydrophila Malnourishment

Necrotizing Infections
Signs/Symptoms
Pain out of proportion to exam Systemic toxicity Ischemic tissues Crepitus

Laboratory
Leukocytosis Hyponatremia

Necrotizing Infections

Laboratory Studies
Blood cultures
Unusual organism Refractory cellulitis Facial involvement Water exposure

CBC Lytes CK levels

Laboratory Studies
Necrotizing STI
WBC > 15.4 and sodium < 135 predictive of necrotizing STI WBS < 15.4 and sodium > 135 had negative predictive value of 99%

Imaging Studies
X-ray
15-30% demonstrate gas

CT
More sensitive than x-ray

MRI
Preferred MRIimaging modality

Diagnostic Algorithm

Treatment Superficial STI

Superficial
Mainly Antibiotics monomicrobial Dicloxacillin aerobes Cephalexin Staphylococcus Erythromycin aureus Clindamycin Streptococcus pyogenes

Treatment Superficial STI

Immune Compromise

Scenario specific
Immune compromised Bites Water exposure Ulcers

H influenza S epidermidis

Animal Bites
P multocida

Seawater/Raw Seafood
V vulnificus

Freshwater
A hydrophila

Treatment Deep STI

Resuscitation Physiologic support Broad spectrum antibiotics Debridement Supportive care
Resuscitation Broad Spectrum Isotonic IV fluids Antibiotics Supportive care Debridement Physiologic support Adjuncts Nutritional Polymicrobial support

The critical step Consider Foley infection failure (70-75%) Renal postpyloric feedings Central lines Reexploration Group Metabolic acidosis A Strep PA catheters mandatory Coverage of defect common (90%) Septic shock Electrolyte Anaerobes correction
Hyponatremia Gram negative rods Hypocalcemia Hyperglycemia

Surgical Debridement
Time from onset of symptoms to initial debridement critical
< 25 hours: 71% survival > 40 hours: 29% survival Clostridial myonecrosis: no survival if surgery delayed 48 hours

Antibiotic Choice
Penicillin/Ampicillin
Eagle effect

Clindamycin Consider aminoglycoside Consider Imipenem

Mortality
Reifler et al, 1988
Limited debridement: 71% mortality Radical debridement: 43% mortality

Overall approximately 30% 63% of deaths due directly from the infection in first week 37% due to multiple system organ failure latter

Synergy of Polymicrobial Infections

Seal and Kingston,1988
GAS: 12% spread GAS and S. aureus: 50% spread GAS and a-lysin: 75% spread

Clostridium Exotoxins
a-toxin
Cell membrane destruction

q-toxin
WBC inhibition

Other toxins
Platelet aggregation

Streptococcal Toxins
M proteins
Prevent phagocytosis Induce vascular leak Cleave NAD

SPE
Induce inflammatory cytokines

Superantigens

Surgical Site Infections

3rd most common nosocomial infection (14-16%) Increase cost and length of stay Most common nosocomial infection on surgical services

Surgical Wound Infection Task Force

77% of deaths with 60-80% of infections nosocomial involve the incision infections present 20-40% of infections due to infection involve the deep 93% of these spaces accessed or infections involved organs operated organs or spaces upon accessed during surgery

Pathogenesis

Host factors Inoculum size Length of operation

Host Factors
Nicotine Remote infections Colonization Blood products

Anticipated Organisms

Guidelines for Prevention of Surgical Site Infection, 1999

Surgical Wound Classification

S. pyogenes

Clostridium sp.

Class I Wound (Clean)

Atraumatic wound without inflammation Do not enter GI, GU, biliary, or respiratory tract 1.5% infection rate

Class II Wound (Clean-Contaminated)

Respiratory, GI, GU, or biliary tract entered under controlled conditions 7.5% infection rate expected

Class III Wounds (Contaminated)

Traumatic wounds Breaks in sterile technique Gross spillage from GI tract Acute, nonpurulent inflammation 15% anticipated infection rate

Class IV Wounds (Dirty)

Old traumatic wounds Devitalized tissue Clinical infection present Perforated viscus 40% expected infection rate

SENIC Risk Index

Abdominal operation Operation greater than 2 hours Class III or IV surgical wounds Three or more diagnosis at time of discharge
Risk of Infection 0 1% 1 3.6% 2 9% 3 17% 4 27%

NNIS Risk Index

1 Normal healthy patient ASA score above disease 2 2 Mild systemic Level of 3 Severe systemic disease contamination 4 Life threatening systemic disease Operative time 5 greater Moribund patient with less than 24 hr life than 75 expectancy percentile of normal 6 Organ donation

NNIS Risk Index

Risk Factors 0 Clean Clean Contaminated 1.0% 2.1% 1 2.3% 4.0% 2 5.4% 9.5%

Contaminated

3.4%

6.8%

13.2%

Surgical Prophylaxis
Wound Classification I II-Biliary,GU, Upper Digestive II-Distal Digestive III/IV Antibiotic PCN Allergy

1st generation Cephalosporin 1st generation Cephalosporin 2nd generation Cephalosporin

Vancomycin Clindamycin Vancomycin Clindamycin

Aztreonam and Clindamycin/Flagyl

Generally Therapeutic

Summary
Superficial soft tissue infection
Generally monomicrobial aerobic gram positives Dont forget specific scenarios for unusual organisms (ex: ulcers, water exposure)

Deep soft tissue infections (necrotizing)

Polymicrobial is the norm Rapidly fatal without surgical intervention

Summary
Polymicrobial infections display synergy from toxin production
Affect vascular supply, cause cell disruption, and inhibit immune response Virulent strains of Group A Streptococcus and Clostridial sp. extremely effective at these functions

Summary
Surgical site infections are a definite problem in health care Factors involved in surgical site infection development
Host factors Inoculum size Length of operation

Summary
Discussed several risk stratification schemes
Surgical Wound Classification SENIC index NNIS risk index

Prophylactic antibiotic choice