Management for Serious Surgical Infection

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• Management for Serious Surgical Infection

Paul Lai Surgery, CUHK
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surgeons enemies

• infection
• bleeding
• reconstruction
• tissue healing
• lack of patients

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Every operation in surgery is an experiment in
bacteriology.
Berkely Moynihan (1920)
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Outline of the talk

• Historic perspectives of surgical infection
• Biology of surgical infection
• Infection control and prevention
• Diagnosis and management of serious surgical
  infection
• Acquired surgical infections

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Outline of the talk

• Historic perspectives of surgical infection
• Biology of surgical infection
• Infection control and prevention
• Diagnosis and management of infection
• Acquired surgical infections

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History - surgical infection

• Louis Pasteur
• Hypothesis of micro-organisms
• Joseph Lister (18271912)
• Carbonic acid spray
• Anti-sepsis and asepsis
• William Halsted (18521922)
• Promote hand washing and gloves
• Alexander Fleming (18811955)
• Discovery of penicillin

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Outline of the talk

• Historic perspectives of surgical infection
• Biology of surgical infection
• Infection control and prevention
• Diagnosis and management of infection
• Acquired surgical infections
• Case presentation

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Risk of wound infection
Type Definition Example Infection risk ()
Clean No breech of GIT Hernia repair 2
Clean-contaminated Prepared GIT Elective colectomy 5
Contaminated Unprepared bowel opened Emergency colectomy 15
Dirty Pus at operative site / perforated bowel Perforated appendicitis 40
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Outline of the talk

• Historic perspectives of surgical infection
• Biology of surgical infection
• Infection control and prevention
• Diagnosis and management of infection
• Acquired surgical infections
• Case presentation

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Surgical Site Infections

• Despite extensive use of disinfectants,
  anti-septics and sterilization procedures in
  patients and instruments, SSI remains the second
  most common cause of nosocomial infection
• Patients who develop SSI are up to 60 more
  likely to spend time in the ICU, 5 times more
  likely to be readmitted, 2 times more likely to
  die than are patients without an SSI

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General recommendation from National Surgical
Infection Prevention Project of CDC

• Antimicrobial prophylaxis
• identify high risk patients and procedures
• timing and duration
• choice of antibiotics
• intra-operative dosing

CID 200438 1706-1715
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General recommendation from National Surgical
Infection Prevention Project of CDC

• 1) Antimicrobial prophylaxis
• Achieve serum and tissue drug levels that exceed
  the MICs (Minimal Inhibitory Concentrations) for
  the organisms likely to be encountered during the
  operation
• Initiated within 60 min of incision on
  induction
• For Fluoroquinolones and vancomycin infusions
  begin within 120 min before incision, because it
  would take 60 min for slow infusion

CID 200438 1706-1715
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General recommendation from National Surgical
Infection Prevention Project of CDC

• 2) Duration
• Majority of published evidence demonstrates that
  antimicrobial prophylaxis after wound closure is
  unnecessary, no additional benefits
• Prolonged use asso. with emergence of resistant
  strains
• End within 24 hour after the operation
• Single exception cardiothoracic surgery, up to
  72 hours

CID 200438 1706-1715
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General recommendation from National Surgical
Infection Prevention Project of CDC

• 3) Choice of antibiotics
• Clean target against Gram positive organism
  cefazolin or cefuroxime
• Cut across mucosa eg GI surgery Gram positive,
  Gram negative and anaerobes cefuroxime plus
  metronidazole
• B lactam allergy alternative clindamycin or
  vancomycin
• Known MRSA colonization vancomycin as
  prophylaixs
• Mupirocin application - can eradicate nasal
  colonization of Staph aureus but do not
  demonstrate reduction of SSI rates

CID 200438 1706-1715
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General recommendation from National Surgical
Infection Prevention Project of CDC

• 4) Intra-operative dosing
• Indicated when the duration of surgery exceed 2
  times of the half life of the antibiotics

Anitibiotics Half life (hr) Redosing interval (hr)
Cefuroxime 1-2 3-4
Metronidazole 6-14 6-8
Gentamicin 2-3 3-6
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Other recommendations from CDC

• Anaesthesia
• maintain normothermia intra-operatively
• peri-operative optimisation of oxygen tension
• maintain glucose control in DM patients

• Patient and OT
• stop smoking prior to surgery
• avoid shaving, use clips for hair removal
• pre-op shower with anti-septic soap
• sterile operating room from filtered air to
  instruments

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Some minor things that surgeons can do
X

• wear a mask
• wear sterile gloves
• keep the nails short
• scrub properly
• talk less during surgery

• reduce bleeding
• gentle tissue handling
• delayed primary closure for heavily contaminated
  wounds
• exclude infected surgeons

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Surgical Site Infections Surveillance

• Criteria according to NNIS ( National Nosocomial
  Infection Surveillance )
• Including Post Discharge Surveillance
• 30 days after the operation
• Quarterly and yearly report
• Overall infection rates
• Distribution by team
• Surgeon specific rates (coding) with infected
  patient list attached (for verification if
  required)
• Distribution by surgery types

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SSI rates compared to reference
39.9
26.3
21.3
15.4
14.6
13.3
11.3
8.7
9.1
6.3
7.5
1.4
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Outline of the talk

• Historic perspectives of surgical infection
• Biology of surgical infection
• Infection control and prevention
• Diagnosis and management of infection
• Acquired surgical infections
• Case presentation

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Diagnosis and management of surgical infection

• history and physical examination
• timing of post-operative infection
• blood tests
• microbiological analysis
• radiological imaging
• resuscitation
• fluid and electrolytes
• analgesia
• anti-emetics
• empirical antibiotics treatment

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post-operative peritonitis
negative abdominal CT
positive abdominal CT
if other infections found
rule out other infections
accessible by percutaneous method
not accessible by percutaneous method OR severe se
psis
percutaneous aspiration or drainage
treat accordingly
consider abdominal re-exploration
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Surgical principles on exploration

• do drain the drainable and leave drainage tubes
  behind (concept of controlled fistulation)
• do debride the obviously dead or ischaemic
  tissues
• do create stomas if anastomosis is risky
• do bear in mind the concept of damage control
  surgery
• do plan re-exploration if necessary
• dont sit too tight on conservative or
  interventional radiological treatments
• dont get into the theatre too late

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Liver abscess
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Liver Abscess
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Gross specimen of a liver abscess
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Severe necrotizing pancreatitis
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Severe necrotizing pancreatitis
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From the previous patient
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Sepsis leading to SIRS MODS

• GI tract as a reservoir of bacteria
• Bacterial translocation as a result of mucosal
  barrier breaking down
• Translocation is promoted by hypovolaemic shock,
  intestinal obstruction and malnutrition
• Bacteria and endotoxin can then trigger release
  of pro-inflammatory cytokines locally and
  systemically
• Left untreated, systemic inflammatory response
  syndrome (SIRS) and multi-organ dysfunction
  syndrome (MODS) would set in

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Management strategies in patients with severe
sepsis

• Stop bacterial spillage into systemic circulation
• correct surgical pathologies
• correct factors that would enhance bacterial
  translocation
• selective use of antibiotics (-)
• enteral nutrition (?) to keep the gut barrier
  intact
• probiotics, glutamine or anti-oxidants,
  dopexamine
• Organ support
• aggressive monitoring of cardiac output, blood
  flow and tissue oxygenation
• get the fluid, inotropes and ventilatory support
  right
• concept of goal-directed therapy

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Outline of the talk

• Historic perspectives of surgical infection
• Biology of surgical infection
• Infection control and prevention
• Diagnosis and management of infection
• Acquired surgical infections
• Case presentation

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Acquired surgical infections

• The operative sites
• Wounds
• Cavities
• In relation to a prosthesis
• Respiratory tract
• Gastrointestinal tract
• pseudomembranous colitis
• Urinary tract
• Intravenous lines
• Cross infections

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MRSA
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Methicillin-resistant staphylococcus aureus
(MRSA)

• It is a by-product of modern and advanced medical
  care
• Rapid rise in incidence all over the world since
  1990
• Serious financial implications for the treatment
  of MRSA infection
• MRSA is around us silently and being
  opportunistic

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Rates of MRSA in ICU during SARS
Yap FH et al., Clin Infect Dis 2004 39511-516.
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Which organ did the MRSA affected?
Yap FH et al., Clin Infect Dis 2004 39511-516.
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Ventilator-associated pneumonia (VAP)

• Higher incidence of bacteraemia, septic shock and
  mortality in MRSA infection
• Vancomycin therapy for MRSA is not very
  satisfactory
• Linezolid (Zyvox) has superior tissue penetration
  compared with glycopeptides
• Linezolid initial therapy for MRSA HAP/VAP is
  associated with significantly better survival and
  clinical cure
• Linezolid was an independent predictor of
  survival in MRSA VAP
• 
  Kollef MH e al., 2004 30388-394.

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Significant predictors of clinical cureVAP
patients (n434)
OR 1.6, p0.048
Mech vent lt7days
OR 5.6, p0.02
Cr lt2.6 mg/dl
OR 2.0, p0.001
Age lt65y
OR 1.6, p0.04
Single lobe
OR 2.8, plt0.001
APACHE II score
OR 1.8, p0.008
Linezolid therapy
0
1
2
3
4
5
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Kollef M, et al. Intensive Care Med 2004 30
388-94
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Surgical site MRSA infection

• Linezolid (Zyvox) is better for surgical site
  MRSA infection
• 98 vs. 48 microbiologically cured P0.0022
• Weigelt J et al., Am
  J Surg 2004 188760-766
• Issues to consider
• Myelosuppression (thrombocytopenia more commonly
  seen in patients treated for gt2 weeks)
• Cost of treatment
• relatively little data on the use of Linezolid in
  intra-abdominal sepsis

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Percentage of MRSA in staphylococcus aureus
bacteraemia
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What did we do about it?

• (1) Audit
• Hand hygiene after removal of gloves
• Hand hygiene after contact with patient's intact
  skin, i.e. physical exam, lifting
• Wash hands before after invasive procedures
  e.g. injection, I.V. insertion, blood taking,
  care of long line, suction
• Wash hands after handling contaminated
  items/site e.g. bedpans, urine bag, incontinence
  pad, wastes, wound dressing

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What did we do about it?

• (2) Hand washing campaign

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alcohol-based handrubs are more efficient
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NTEC Hand Hygiene Audit Overall Compliance
() Compliance Rate
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New MRSA isolates per 1000 DD
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ESBL-producing bacteria

• ESBL stands for extended spectrum
  beta-lactamase
• Not a single enzymes but gt170 ESBLs
• Most commonly found in E.Coli and Klebsiella
  pneumonia
• People with weaker immunity are at risk
• Can spread through contacts (e.g. healthcare
  workers)

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ESBL-producing bacteria - issues

• Difficult to detect need more intensive
  screening and susceptibility tests
• Its prevalence is probably underestimated
• High risk groups
• Emergency intra-abdominal surgery
• ICU stay with all sorts of lines and tubes
• Prior antibiotics treatments
• Treatment is difficult
• Total resistance
• Clinical reduction in efficacy on standard dose

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Infection control - ESBL

• Antibiotic selection pressure
• Plasmid carrying ESBL genes can be disseminated
  through species
• Restrict use of antibiotics especially
  cephalosporins
• Contact precautions (gloves and gowns)

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Thank You
www.surgery.cuhk.edu.hk