Surgical Infections Taken from the lecture of: RENATO R.

MONTENEGRO, MD, FPSGS Compiled by Arvin 08/26/08 TREATMENT History Pre-anesthetic, pre-Listerian era 1842 Anesthesia (Morton and Long) 1865 The antiseptic principle or Listerian method 1880 - 1890 Aseptic Surgery 1940 Antibiotic use History Pre-anesthetic, pre-Listerian era surgical history = death from infection mortality rates for amputation in times of war (1745 and 1865) = 25 to 90 % The Antiseptic Principle, 1865 Joseph Lister demonstrated that antisepsis could prevent infection 1867 publication: compound fractures healed without infection when the wounds were treated with carbolic acid. The Listerian Method emphasized antiseptic treatment of wounds after the operation History (1880 1890 , Aseptic Surgery) William Stewart Halsted = rubber gloves, hand washing, masks, caps, gowns Ernst Bergman = chemical and steam sterilization of instruments Today, we wash our hands before an operation Antibiotic Era End of the 19th century - bacterial cause of surgical infection was appreciated Discovery of Penicillin (Alexander Fleming, 1928) Clinical use of Penicillin (Howard Florey, 1940)

Typically, they possess virulence properties Antibiotics

usually originate from the patient's own endogenous flora Surgical or other invasive procedure

TYPES OF SURGICAL INFECTIONS Soft Tissue Infections (Cellulitis and Lymphangitis, Necrotizing Soft Tissue Inf., Tetanus) Prosthetic DeviceAssociated Infections (cardiac valves, pacemakers, vascular grafts, and artificial joints) Body Cavity Infections (Peritonitis and Intraabd. Abscess, Empyema, Other ClosedSpaced Infections) Nosocomial Infections (urinary tract infections, wound infection, lower respiratory infection, vascular catheterrelated) Principles of Therapy host defenses and antibiotic therapy are adequate to overcome most infections operative tx is generally required when host defenses cannot function properly or when there is continuing contamination with microorganisms non-operative treatments hasten recovery (chest physiotherapy, increase fluid intake, immobilization and elevation of extremity) Why Surgery is required Control of septic focus Drainage of infected fluid collections Debridement of infected necrotic tissue Removal of infected foreign bodies Correction of anatomic abnormalities Abscesses phagocytic cells cannot function properly with the metabolic conditions in abscesses antibiotics penetrate abscesses poorly antibiotics work best on actively dividing bacteria necrotic tissue and foreign bodies inhibit the proper functioning of host defenses Infections resulting from operative tx surgical wound infection - Surgical site infection postoperative abscess postoperative (tertiary) peritonitis and other body cavity infections prosthetic devicerelated infection hospital-acquired infections Types of Surgical Infections Superficial Incisional SSI Deep Incisional SSI Organ/Space SSI

(FIGURE 47-2) Mortality rates from appendicitis since 1880. The landmak paper by Fitz was published in 1886. Penicillin became widely available in the late 1940s. Surgical Infections defined as infections that require operative treatment or result from operative treatment Medical vs Surgical Infections MEDICAL INFECTIONS COMMUNITY host defenses are ACQUIRED usually INFECTIONS intact PATHOGENS usually single and aerobic

SURGICAL INFECTIONS result of damaged host defenses frequently mixed, aerobes and anaerobes; pathogens are opportunistic

Use of Antibiotics in Surgery Prophylactic Antibiotics Therapeutic Use of Antibiotics Empiric Therapy Definitive Therapy Surgical wound classification Based on theoretical number of bacteria present in the wound Predicts the likelihood of developing wound infection Basis for use (or non-use) of antibiotics Basis for prophylactic vs therapeutic use of antibiotics

Definition of Surgical Wound Infection Superficial Surgical Wound Infection Infection at incision site above the fascial layer within 30 days after operation plus any of the ffg: There is purulent drainage from the incision or a drain site. An organism is isolated from culture of fluid that has been aseptically obtained from a wound that was closed primarily. The wound is opened deliberately by the surgeon, unless the wound is culture-negative Deep Surgical Wound Infection Infection at operative site at or beneath fascial layer w/in 30 days after operation if no prosthesis was used and w/in 1yr if an implant was used plus any of the ffg: The wound spontaneously dehisces or is deliberately opened by the surgeon when the patient has a fever (>38 C) and/or there is localized pain or tenderness, unless the wound is culture-negative. An abscess or other evidence of infection directly under the incision is seen on direct examination, during operation, or by histopathologic examination. The surgeon diagnoses infection. Determinants of Infection Microbial Pathogenicity Host Defenses Local Host Defenses Systemic Host Defenses The Wound Surgical Technique

Wound Classification WOUND CLASS INFECTION RATES Clean 1.5 to 3.9 % (<2%) Clean contaminated 3.0 to 4.0 % Contaminated 8.5 % Dirty 28 to 40 %

ANTIBIOTIC USE None Prophylactic Therapeutic Therapeutic

Treatment Failure in Surgical Infections 1. The initial operative procedure was not adequate. 2. The initial procedure was adequate but a complication has occurred. 3. A superinfection has developed at a new site. 4. The drug of choice is correct, but not enough is being given. 5. Another or a different drug is needed.