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Surgical Infections

Guo Xueli ( 郭学利 )

Dept. General Surgery, First Affiliated


Hospital
Nature, Diagnosis, and Treatment of Surgical Infections
Surgical infections are distinguished from medical
infections by the presence of an anatomic or mechanical
problem
Surgical infections must be resolved by operations or other
invasive procedure to cure
---incising and draining an abscess, opening an infected
wound, removing an infected foreign body, repairing or
diverting a bowel leak, and draining an intra-abdominal
abscess with a percutaneous
---only antibiotic treatment will not resolve
---operative intervention is required
The typical differences
Common community-acquired medical infections
---general host defense are usually intact
---some exceptions to intact host defense occur
in patients undergoing systemic treatment for
malignancy or for transplant rejection and
patients with HIV infection
Most surgical infections
---the result of damaged host defense, especially
injury to the epithelial barrier
Immunologic defects may be acquired, through
either trauma or tumor
---nonmechanical host defense defects are global,
caused by nutritional deficiency and /or the
systemic effects of trauma
Pathogens
---single and aerobic in medical infections
---mixed in surgical infections, involving
aerobes and anaerobes, and usually originate
from the patient’s own endogenous flora.
The pathogens are opportunistic, often
depending on an acquired epithelial defect to
cause infection.
Soft tissue infections
The distinction between surgical and medical
infection in superficial tissues---depends on
the recognition of dead tissue
A surgical infection
#a subcutaneous abscess, an infectious process
characterized by a necrotic center without a
blood supply and composed of debris from
local tissues and plasma, and bacteria
#the semiliquid central portion (pus)---surround
by a vascularized zone of inflammatory tissue.
#a localized swelling with signs of inflammation
and tenderness
#an abscess will not resolve unless the pus is
drained and evacuated
Cellulitis
---another soft tissue infections with intact blood
supply and viable tissue, marked by an acute
inflammatory response with small vessel
engorgement and stasis, endothelial leakage with
interstitial edema, and polymorphonuclear
leukocyte infiltration
---resolves with appropriate antibiotic therapy alone
if treatment is initiated before tissue death occurs
An abscess
---may be mistaken for cellulitis when the central
necrotic portion is located deep beneath
overlying tissue layers
---also be disguised in anatomic locations where
fibrous septa join skin and fascia, dividing
subcutaneous tissue into compartments that limit
the local expression of fluctuance while leading
to high pressures
#include perirectal abscess, breast abscess,
carbuncles on the posterior neck and upper back,
and infections in the distal phalanx of the finger
(felon)
Perirectal abscess
---a fistula communicating with the anus at a
crypt, should be sought and unroofed at the
time a perirectal abscess is drained
Breast abscess
---preferably drained by a circumferential
incision in natural skin lines
Felon---be drained through a lateral incision,
all fibrous septa in the infected pulp must be
broken to resolve the infection
Superficial abscess
On the trunk and head and neck---caused by S.
aureus, often combined with streptococci.
In the axillae---have a prominent gram-negative
component.
Below the waist, especially on the perineum---a
mixed aerobic and anaerobic gram-negative
flora.
Necrotizing soft tissue infections
#clostridial and nonclostridial
#less common, but much more serious condition
#marked by the absence of clear local boundaries
or palpable limits
#the overlying skin has a relatively normal
appearance in the early stages of infection
A clostridial infection
---typically involves underlying muscle, termed
clostridial myonecrosis or gas gangrene
Most nonclostridial and some nonclostridial
necrotizing infections
---spread in the subcutaneous fascia, between
the skin and the deep muscular fascia, called
necrotizing fasciitis
The earliest signs of a necrotizing soft tissue infection
---a marked hemodynamic response to infection, or the
failure to respond to conventional nonoperative
therapy
An apparent cellulitis with ecchymoses, bullae, any
dermal gangrene, extensive edema, or crepitus
---underlying necrotizing infection
---mandates operative exploration to confirm the
diagnosis and definitively treat the infection
Diagnosis
---to recognize the nonlocalized, necrotizing nature of
the infection and the need for operative treatment
Operative treatment
Clostridial myonecrosis---excision of involved tissues
or amputation (on an extremity)
Nonclostridial infection---wide incision and
debridement and do not usually require amputation
In either case---all areas of necrotic tissue must be
unroofed and debrided, which often produces large
disfiguring wounds.
Organisms
Clostridial infection---Clostridium perfringens, C.
novyi, and C. septicum
Nonclostridial infection---beta-hemolytic
S.pyogens
Postoperative and postinjury cases---most often
caused by mixed bacterial species, including
aerobic and anaerobic pathogens, both gram
positive and gram negative
Intra-abdominal and retroperitoneal infection

#most serious intra-abdominal infections---require


surgical intervention
#the specific exceptions---pyelonephritis,
salpingitis, amebic liver abscess, enteritis,
spontaneous bacterial peritonitis, some cases of
diverticulitis, and some case of cholangitis
Fever, tachycardia, and hypotension---common
A severe hypermetabolic, catabolic response
---universal
#No corrective operation and effective antibiotics
---multiple-organ failure syndrome---death
#Early diagnosis and treatment
---improve the outcome
#the risk of death and of complication---increases
with increased age, pre-existing serious
underlying diseases, and malnutrition
Initial treatment
Cardiorespiratory support, antibiotic therapy, and
operative intervention
In most cases
The responsible bacteria---are not known
No sensitivity information
Three to five different aerobic and anaerobic pathogens
#Initial antibiotic therapy
---empiric, designed to cover a range of possible
organisms
Operative intervention for intra-abdominal or
retroperitoneal infection

The goal---is to correct the underlying anatomic


problem that either caused the infection
or perpetuates it
#the cause of peritonitis---must be corrected
#foreign material (feces, food, bile, mucin, blood) in
the peritoneal cavity---should be removed
#large deposits of fibrin---should be removed
An intra-abdomial or retroperitoneal abscess
---requires drainage
#the abscesses---single and has a straight path to
the abdominal wall that does not transgress
bowel
---to be drained percutaneously under
radiologic or ultrasound guidance
# the abscesses---multiple or combined with
underlying disease, no safe percutaneous route
---to be drained by an open operation
*A single abscess in the subphrenic or subhepatic
position---an extraperitoneal subcostal or
posterior twelfthrib approach, which provides
open drainage without exposing the entire
peritoneal cavity
*Most pancreatic abscesses---transabdominal
operation and debridement
*A pelvic abscess---transrectal or transvaginal
*Retroperitoneal phlegmon (necrotizing
cellulitis)---extensive debridement
Postoperative fever
Approximately 2% of all primary laparotomies are
followed by an unscheduled operation for intra-
abdominal infection
Roughly 50% of all serious intra-abdominal
infections---postoperative
Postoperative fever---occurs frequently and may
be a source of concern to physician and patient
#Fever is associated with infection
The empiric prescription of antibiotics is
common response
However, most febrile postoperative patients
---not infected
A significant proportion of infected patients
---not febrile
#It is important to consider causes of
postoperative fever
Diagnosis for detecting infection and determining
its location
---taking history, physical examination
---supportive laboratory and x-ray evaluation,
including white blood cell count, blood
cultures, and CT, can supplement the physical
examination
Fever
#in the first 3 days after operation---
noninfectious cause
#starts 5 or more days postoperatively---the
incidence of wound infections exceeds the
incidence of undiagnosed fevers
Only two important infectious cause in the first
36 hours after a laparotomy
---an injury to bowel with intraperitoneal leak
---an invasive soft tissue infection
#an injury to bowel with intraperitoneal leak
---Marked hemodynamic change---first tachycardia
and then hypotension and a falling urine output
---Fluid requirements are large
---Physical examination reveals diffuse abdominal
tenderness
#an invasive soft tissue infection
---Beginning in the wound, caused either by beta-
hemolytic streptococci or by clostridial species
---Inspection of the wound and Gram stain of wound
fluid, which shows either gram-positive cocci or
gram-positive rods
Nonsurgical infections in surgical patients
A variety of nonsurgical postoperative nosocomial
infections
Urinary tract infections
---most common, any patient who has had an
indwelling urinary catheter
The best prevention
---to use urinary catheters sparingly and
for specific indications
---to employ strict closed drainage
techniques for those
Lower respiratory tract infection
leading cause of death due to nosocomial infection
---abnormal chest x-ray findings, abnormal blood
gas values, and elevated temperatures and white
blood cell counts even in the absence of infection
Diagnosis
---usually relatively straightforward in a patient who
is breathing spontaneously
---extremely difficult in a patient who is intubated
and being ventilated because of ARDS
Both false-positive and false-negative diagnosis of
pneumonia
Prosthetic device-associated infections
Some of the most significant complication
associated with vascular grafts, cardiac
valves, pacemakers, and artificial joints are
caused by infections at the site of implantation
#the foreign material (the prosthetic device)
---impairs logical host defenses, especially
polymorphonuclear leukocyte function
#high morbidity and mortality
Treatment
#intensive antibiotic therapy
#removal of the infected device under
antibiotic therapy
#replacement with a new uninfected
device followed by prolonged antibiotic
treatment
Pathogens in Surgical Infections

The pathogens are broadly divided into


---aerobic and facultative bacteria in one
group and anaerobic bacteria in the other
---gram-positive and gram-negative bacteria
---bacilli( rods )and cocci
Gram-positive cocci
Include staphylococci and streptococci
Staphylococci
---coagulase-positive and coagulase-negative
strains
Coagulase-positive staphylococci---S. aureus
---Associated with infections in wound and
incisions
---resistant to penicillin and require
treatment by a penicillinase-resistant
antibiotic
---methicillin-resistant staphylococci must
be treated with vancomycin or a similar
agent
Coagulase-negative staphylococci
---contaminants and skin flora
---frequently associated with clinically significant
infections of intravascular devices
---found in endocarditis, prosthetic joint infections,
vascular graft infections, and postsurgical
mediastinitis
---methicillin resistant
---vancomycin should be chosen
Streptococcal species
Include beta-hemolytic streptococci,
S.pneumoniae, and other alpha-hemolytic
streptococci
---to be uniformly sensitive to penicillin G and
almost all other beta-lactam antibiotics
Enterococci
#as part of a mixed flora in intra-abdominal
infection
#it is rare to recover enterococci alone from
a surgical infection
#cause significant disease in the urinary and
the biliary tract
#gentamicin combined with either
ampicillin or vancomycin
Aerobic and facultative gram-negative rods
Most fall into the family Enterobacteriaceae
#the familiar genera Escherichia, Proteus,
and Klebsiella
---in mixed surgical infection
---relatively sensitive to a broad variety of
antibiotics, especially first- and second-
generation cephalosporins
#other genera include Enterobacter,
Morganella, Providencia, and Serratia
---commonly exhibit greater intrinsic
antimicrobial resistance
---requires a third-generation cephalosporin,
one of the expanded-spectrum penicillins, a
monobactam, carbapenem, quinolone, or
aminoglycoside
Anaerobes
Most numerous in the normal gastrointestinal
tract and mouth
The most common---Bacteroides fragilis
#B.fragilis and B.thetaiotaomicron---significant
resistance to many beta-lactam antibiotics
#effective antibiotics---metronidazole,
clindamycin, chloramphenicol, imipenem
#less resistance patterns---Bacteroides
melaninogenicus and most of the anaerobic
cocci
The other important genus---Clostridium
#all gram-positive, spore-forming rods
#C. tetani---responsible for tetanus
the prevention of tetanus
---active and passive immunization
Anaerobic bacteria grow only in settings with
a low oxidation-reduction potential
Majority of anaerobic infections require
surgical intervention
Fungi (from the Candida genus)
---are infrequently the primary pathogens in
deep-seated surgical infections
---may be seen frequently as an opportunistic
invader in patients with serious surgical
infection who have received broad-spectrum
antibiotic treatment suppressing normal
endogenous flora
These infections are best avoided
---through judicious use of systemic broad-
spectrum antibiotics
---through prophylaxis with oral nystatin or
ketoconazole when broad-spectrum antibacterial
therapy is required
Viruses
---don’t not cause any infections that
require operation for resolution
Immune suppression to prevent rejection
---transplant patients are at significant risk of
viral infection---cytomegalovirus
The bloodborne viruses
---may be transmitted through blood
transfusion: HBV, HCV, HIV
#the use of accurate tests for screening
infected units of blood
#to limit blood transfusion to circumstances
clearly requiring it