Post on 21-Dec-2015
What is new in What is new in management of management of Surgical InfectionSurgical Infection
Prof. Ravi KantProf. Ravi Kant
Contents:
Introduction Types of surgical infections Definition of SSI Types SSI Recent management of SSI sepsis Peritonitis
Soft tissue/wound Infictions.Soft tissue/wound Infictions.
ThirdThird most reported nosocomial most reported nosocomial infectionsinfections
16%16% of all reported nosocomial of all reported nosocomial infectionsinfections
Most commonMost common surgical patient surgical patient nosocomial infection (38%)nosocomial infection (38%)
2/3 involved surgical incision2/3 involved surgical incision 1/3 deep structures accessed 1/3 deep structures accessed
by incisionby incision Deaths in patients with Deaths in patients with
nosocomial infections—nosocomial infections—7777% % related to infection.related to infection.
Soft tissue/wound Infictions.Soft tissue/wound Infictions.
EWMA Journal 2005; 5(2): 11-15.
IntroductionIntroduction
< 1900= 70-80% mortality for < 1900= 70-80% mortality for wound infectionwound infection
>1900: Ignaz Semmelweis and >1900: Ignaz Semmelweis and Joseph Lister = antiseptic surgeryJoseph Lister = antiseptic surgery
IntroductionIntroduction
Surgery, trauma, non-trauma Surgery, trauma, non-trauma local invasion can lead to local invasion can lead to bacterial insultbacterial insult..
Once present, bacteria, initiate Once present, bacteria, initiate the host defense processes.the host defense processes.
Inflammatory mediatorsInflammatory mediators (kinins, histamine, etc.) PMN’s (kinins, histamine, etc.) PMN’s arrive, etc.arrive, etc.
IntroductionIntroduction
Surgical infections Surgical infections surgical wound itselfsurgical wound itself or in or in other systems in the patient.other systems in the patient.
They can be initiated not only by They can be initiated not only by “damage” to the host but also “damage” to the host but also by changes in the host’s by changes in the host’s physiologic state.physiologic state.
InfectionsInfections
Two main typesTwo main typesCommunity-AcquiredCommunity-AcquiredHospital-AcquiredHospital-Acquired
Community-AcquiredCommunity-Acquired
Skin/soft tissueSkin/soft tissueCellulitis: Group A strepCellulitis: Group A strepAbcess/furuncle: Staph aureusAbcess/furuncle: Staph aureusNecrotizing: Mixed Necrotizing: Mixed Hiradenitis suppurativa:SHiradenitis suppurativa:Staph aureustaph aureusLymphangitis: Staph aureusLymphangitis: Staph aureus
CellulitisCellulitis
FuruncleFuruncle
Necrotizing Necrotizing
HiradenitisHiradenitis
LymphangitisLymphangitis
Breast AbscessBreast Abscess
Peri-rectal abscessPeri-rectal abscess
Gas GangreneGas Gangrene
ParonychiaParonychia
Diabetic foot infectionDiabetic foot infection
Biliary TractBiliary TractUsually result from obstructionUsually result from obstructionUsual suspects:Usual suspects:
E. coli, Klebsiella, EnterococciE. coli, Klebsiella, EnterococciAcute CholecystitisAcute CholecystitisGB empyemaGB empyemaAscending cholangitisAscending cholangitis
Community-AcquiredCommunity-Acquired
ViralViralHepatitisHepatitisHIV/AIDSHIV/AIDS
Tetanus Tetanus
Hospital-AcquiredHospital-Acquired
Post-operativePost-operative At the surgical siteAt the surgical site Systemic.Systemic.
Infected Vascular GraftInfected Vascular Graft
Inguinal incision is independent risk Inguinal incision is independent risk factorfactor
Length of case and blood lossLength of case and blood loss Prosthetic grafts 10%-20%Prosthetic grafts 10%-20% S. AureusS. Aureus
Gas gangreneGas gangrene
Beta hemolytic streptBeta hemolytic strept Clostridial perfringes (gram pos Clostridial perfringes (gram pos
rods) rarerods) rare 50% polymicrobial50% polymicrobial Rapid lysis of tissues with relatively Rapid lysis of tissues with relatively
little response from hostlittle response from host EndotoxinEndotoxin
Gas gangreneGas gangrene
Aggressive debridement & Aggressive debridement & antibioticsantibiotics
Repeat antibioticsRepeat antibiotics
Catheter SepsisCatheter Sepsis
80% of cases, colonized catheters 80% of cases, colonized catheters had been inserted by inexperienced had been inserted by inexperienced and experienced residents and experienced residents
Key is to identify before sepsis Key is to identify before sepsis developsdevelops
Stapylococcus epidermis, S. Aureus, Stapylococcus epidermis, S. Aureus, yeastyeast
Burn InfectionsBurn Infections
Necrotic tissue readily colonizedNecrotic tissue readily colonized High bacteria counts are High bacteria counts are NOTNOT
a reliable indication of an infected burn a reliable indication of an infected burn Histological examination to determine Histological examination to determine
invasivenessinvasiveness TXTX: debridement and antibiotics: debridement and antibiotics
Hospital-AcquiredHospital-Acquired
PulmonaryPulmonaryPneumoniaPneumonia
Non-ventilator associatedNon-ventilator associated
Ventilator associatedVentilator associated
AspirationAspiration
Hospital-AcquiredHospital-Acquired
Urinary TractUrinary TractDiagnosisDiagnosisUsual suspectsUsual suspects
Pseudomonas, Serratia, Pseudomonas, Serratia, other other
Hospital-AcquiredHospital-Acquired
Foreign-body associatedForeign-body associatedSitesSites
CathetersCathetersLinesLinesProsthetics/graftsProsthetics/grafts
Hospital-AcquiredHospital-Acquired
Wound infection & SSI.Wound infection & SSI.
Surgical wounds are healing Surgical wounds are healing byby
1) Primary intention1) Primary intention 2) Secondary intention2) Secondary intention 3) Delayed primary intention3) Delayed primary intention
Incidence of SSIs →closure/delayed Incidence of SSIs →closure/delayed closure of an infected woundclosure of an infected wound
Opening and re-closure times Re-infection rate %
Opening and re-closure at once
50
Opening and re-closure after two days
20
Opening and re-closure after four days
5
Opening and re-closure after nine days
10
[Gottrup, F. Wound healing and principles of wound closure. In: Holström H, Drzewieck KT (Eds). The Scandinavian Handbook of Plastic Surgery. Malmoe: Studenterliteraturen, 2005
Definition of SSIDefinition of SSI
The CDC : =< 30 days of The CDC : =< 30 days of surgery (or within a year in surgery (or within a year in the case of implants)the case of implants)
Mangram . Guideline for prevention of surgicalsite infection, 1999. Infect Control Hosp Epidemiol 1999;
classificationclassificationincisionalincisionalsurgical site infectionssurgical site infections
Superficial Superficial DeepDeep Organ/spaceOrgan/space
superficial incisional superficial incisional surgical site infectionssurgical site infections
< 30 days of procedure < 30 days of procedure involve only the skin or involve only the skin or
subcutaneous tissue around subcutaneous tissue around the incision.the incision.
Mangram . Guideline for prevention of surgicalsite infection, 1999. Infect Control Hosp Epidemiol 1999
Deep incisional surgical Deep incisional surgical site infectionssite infections
< 30 days of procedure (or one < 30 days of procedure (or one year in the case of implants) year in the case of implants)
are related to the procedure are related to the procedure involve deep soft tissues, such involve deep soft tissues, such
as the fascia and muscles.as the fascia and muscles.
Mangram . Guideline for prevention of surgicalsite infection, 1999. Infect Control Hosp Epidemiol 1999
ASEPSIS WOUND ASEPSIS WOUND SCORING SYSTEMSCORING SYSTEM
[ Wilson AP, [ Wilson AP, LancetLancet 1986 1986
Southampton wound Southampton wound scoring systemscoring system
[Bailey IS, [Bailey IS, BMJBMJ 1992; 304: 469-71 1992; 304: 469-71
Risk FactorsRisk Factors
Surgical factors Surgical factors Patient-specific factorsPatient-specific factors
local local systemicsystemic
Factors influencing SSIsFactors influencing SSIsPatient Risk FactorsPatient Risk Factors
Local:Local:High bacterial High bacterial
loadloadWound Wound
hematomahematomaNecrotic tissueNecrotic tissueForeign bodyForeign bodyObesityObesity
Systemic:Systemic:Advanced ageAdvanced ageShockShockDiabetesDiabetesMalnutritionMalnutritionAlcoholismAlcoholismSteroidsSteroidsChemotherapyChemotherapy Immuno-Immuno-
compromisecompromise
Factors influencing SSIsFactors influencing SSIs
AntibioticsAntibiotics ProphylacticProphylactic TherapeuticTherapeutic
Factors influencing SSIsFactors influencing SSIs
Surgical Risk FactorsSurgical Risk Factors Type of procedureType of procedure Degree of contaminationDegree of contamination Duration of operationDuration of operation Urgency of operationUrgency of operation skin preparation skin preparation operating room environmentoperating room environment Antibiotic prophylaxis Antibiotic prophylaxis
EWMA Journal 2005; 5(2): 11-15.
Wound class Definition Example Infection rate (%)
Clean Nontraumatic, elective surgery. GI tract, respiratory tract, GU tract not entered
Mastectomy Vascular Hernias
2%
Clean-contaminated
Respiratory, GI, GU tract entered with minimal contamination
Gastrectomy Hysterectomy
< 10%
Contaminated Open, fresh, traumatic wounds, uncontrolled spillage, minor break in sterile technique
Rupture appy Emergent bowel resect.
20%
Dirty Open, traumatic, dirty wounds; traumatic perforation of hollow viscus, frank pus in the field
Intestinal fistula resection
28-70%
Berard F, Gandon J, Ann Surg 1964
Reduce hemoglobin A1c levels to <7% before operation
Evidence Class II data
References Anderson DJ, Kaye KS, Classen D, et
al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;
Smoking cessation 30 d before operation
Evidence Class II data
References Anderson DJ, Kaye KS, Classen D, et
al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008
Remove hair only if it will interfere with the operation; hair removal by clipping immediately before the operation or with depilatories; no pre- or perioperative shaving of surgical
Evidence Class I data
References Kjønniksen I. Preoperative hair removal– a systematic literature review. AORN J 2002
Use an antiseptic surgical scrub or alcohol-based hand antiseptic for preoperative cleansing of the operative team members’ hands and forearms
Evidence Class II data
References Anderson DJ. Strategies to prevent
surgical site infections in acute care hospitals.
Infect Control Hosp Epidemiol 2008;
Prepare the skin around the operative site with an appropriate antiseptic agent, including preparations based on alcohol, chlorhexidine, or iodine/iodophorsEvidence Class II data
References Anderson . Strategies to prevent
surgical site infections in acute care hospitals.
Infect Control Hosp Epidemiol 2008;
Administer prophylactic antibiotics for most clean-contaminated and contaminated procedures, and selected clean procedures use antibiotics appropriate for the potential pathogens
Evidence Strong Class I data
References Springer R. The Surgical care improvement
project-focusing on infection control.Plast Surg Nurs 2007;
Administer prophylactic antibiotics within1 h before incision (2 h for vancomycin and fluoroquinolones)
Evidence Strong Class II data
References Springer R. The Surgical care
improvement project-focusing on infection control.Plast Surg Nurs 2007
Use higher dosages of prophylactic antibioticsfor morbidly obese patients
Evidence Limited Class II data
References Springer R. The Surgical care
improvement project-focusing on infection control.Plast Surg Nurs 2007
Carefully handle tissue, eradicate dead space, and adhere to standard principles of asepsis
Evidence Class III
References Anderson DJ. Strategies to prevent
surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;
Redose prophylactic antibiotics with short half-lives intraoperatively if operation is prolonged (for cefazolin if operation is >3 h) or if there is extensive blood loss
Evidence Limited Class I, Class II data
References Scher K. Studies on the duration of
antibiotic administration for surgical prophylaxis Am Surg 1997
Maintain intraoperative normothermiac
Evidence Class I; some contradictory Class II
data
References Sessler DI, Akca O.
Nonpharmacological prevention of surgical wound infections.
Clin Infect Dis 2002
Discontinue prophylactic antibiotics within 24 h after the procedure (48 h for cardiac surgery &liver transplant procedures) discontinue prophylactic antibiotics after skin closure
Evidence Class I; meta-analyses support single dose
regimens for prophylaxis References ASHP Therapeutic guidelines on antimicrobial
prophylaxis in surgery. Am J Health Syst Pharm 1999
Maintain serum glucose levels <200 mg/dL on PO
Evidence Class II data
References Anderson DJ. Strategies to prevent
surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008
Monitor wound for the development of SSI postoperative days 1 and 2d
Evidence Class III data
References Anderson DJ. Strategies to prevent
surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008
• opening the wound I&D .• For most patients who have had their wounds opened and adequatelydrained, antibiotic therapy is unnecessary.
Treatment of SSI
Stevens DL. Prguidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis 2005actice
o use antibiotics only when there are significant systemic signs of infection
(temperature higher than 38.5Cor heart rate greater than 100
beats/min) erythema extends more than 5 cm
from the incision.Stevens DL. Prguidelines for the diagnosis and management of skin and
soft-tissue infections. Clin Infect Dis 2005actice
Treatment of SSI
Sepsis Sepsis
Sepsis:Sepsis: Commonly called a Commonly called a "blood stream infection.“"blood stream infection.“
The presence of bacteria The presence of bacteria (bacteremia) or other infectious (bacteremia) or other infectious organisms or their toxins in the organisms or their toxins in the blood (septicemia) or in other blood (septicemia) or in other tissue of the body. tissue of the body.
SepsisSepsis
Sepsis may be associated with clinical Sepsis may be associated with clinical symptoms of systemic (bodywide) symptoms of systemic (bodywide) illness, such as fever, chills, malaise , illness, such as fever, chills, malaise , low blood pressure, and mental status low blood pressure, and mental status changes. changes.
Sepsis can be a serious situation, a life Sepsis can be a serious situation, a life threatening disease calling for urgent threatening disease calling for urgent and comprehensive care. and comprehensive care.
Sepsis, Septic shockSepsis, Septic shock
Signs of:Signs of:Increased C.O.Increased C.O.Altered OAltered O22 SATURATION. SATURATION.Metabolic acidosis (usually)Metabolic acidosis (usually)
Can lead to ---Death.Can lead to ---Death.
SepsisSepsis
Sepsis remains a major clinical Sepsis remains a major clinical problem for 21problem for 21stst century century
marginal improvement in the marginal improvement in the mortalitymortality
antibiotics are cornerstone antibiotics are cornerstone
10% improvement in mortality10% improvement in mortality
Mac Arthur RD et al.Adequacy of early empiric antibiotic treatment in severe sepsis experience from MONARCS trial . Clin Infect Dis 2004;38(2):284-88
Cytokines ReleaseTNF , IL1
IL6,10 Protease ,PG
PAF
Endothelial injury
Coagulopathy
Tissue factor
Fibrin clot
Inhibit activity Protein C
Antithrombin III
Suppress fibrinolysis
The aimThe aimSepsis is condition diagnosed on the bases Sepsis is condition diagnosed on the bases of clinical & laboratory parameters of clinical & laboratory parameters
increased level of inflammatory mediators increased level of inflammatory mediators reflects global dysregulation of immune reflects global dysregulation of immune response response
Examine the latest evidence for the use of Examine the latest evidence for the use of immuno-modulating drugs obtained from immuno-modulating drugs obtained from human clinical trialshuman clinical trials
immune response is multi-immune response is multi-faceted faceted
Aim :Aim :Eliminate
invading object
Maintainhomeostasis
Limit tissue damage
Sepsis And host response
More than adequate or
Inadequate.
Inadequate Host response
Stimulation by LevamisolePro inflammatory Cytokine
interferon yAnti- prostaglandins
(immunosuppressive mediators
IL-10
IL- 10 administration improves survival following endotoxin challenge
Live candida - block IL-10- improves survival
More than adequate host response
Anti-inflammatory cyotkines like Interleukin 10
Agents to neutralise tumor necrsois factor or interlekin -1
Severity assessment
PAC- initially Ultra low frequency ossillations in
CO/global end diastolic vol -severity high Lactate levels –good severity predictor Low exogenous clearance – very early
predictor of mortality C reactive protein – high risk of organ
failure/ too slow to monitor
Management of SepsisManagement of Sepsis
Hemodynamic, respiratory Hemodynamic, respiratory stabilitystability
Source control in sepsisSource control in sepsis Early enteral feed/intensive insulin Early enteral feed/intensive insulin
therapytherapy stress ulcer prophylaxis, and deep stress ulcer prophylaxis, and deep
vein thrombosisvein thrombosis Daily hemodalysis –Daily hemodalysis – better survival better survival
Early goal-directed therapy (EGDT)
Oximetric central venous catheters were placed to measure central venous pressure
(CVP) & CvO2 500-mL aliquots of isotonic
crystalloid were given by bolus infusion to achieve a central venous pressure greater than 8 mm Hg.
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatmentof severe sepsis and septic shock. N Engl J Med 2001;
Early goal-directed therapy (EGDT)
Mean arterial pressure was maintained at 65 mm Hg or higher with vasopressors.
If the CvO2 saturation was still less than 70%, blood was transfused to a hematocritof 30.
If the CvO2 saturation was still less than 70%, dobutamine was started.
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatmentof severe sepsis and septic shock. N Engl J Med 2001;
Early goal-directed therapy (EGDT)
Mortality was significantly lower among patients randomized to EGDT (48.2% versus
33.3%, P 5 .01).
Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatmentof severe sepsis and septic shock. N Engl J Med 2001;
SepsisSepsis
it is complex process and the it is complex process and the goal of immune therapy is goal of immune therapy is identifying critical point of identifying critical point of response to modulate itresponse to modulate it
TNFTNF
TNF is an important mediator TNF is an important mediator of sepsisof sepsis
Serum level correlate with Serum level correlate with outcomeoutcome
Immunotherapy : Immunotherapy :
- Antibodies- Antibodies
- Blocking receptor - Blocking receptor Calandra T et al.Prognostic values of tumor necrosis factor/cachectin,interlukin-
1,interferon-alpha and interferon gamma in the serum of patients with septic shock. J Infec Dis 1990;161:982-87
Blockade of tumor necrosis factor
Improves outcome in E. coli septicemia.
But increased mortality with cecal ligation and puncture.
TNF antibody
NEROCEPT :NEROCEPT :
reduction of mortality 1reduction of mortality 1stst 3 3 days - dose dependant days - dose dependant
INTERSEPT :INTERSEPT :
-reduce progression of sepsis-reduce progression of sepsis
- rapid resolution of shock - rapid resolution of shock
TNF antireciptor:
Recombinant receptor :Recombinant receptor :
- dose dependant increase - dose dependant increase in mortalityin mortality
- deleterious effect in - deleterious effect in human clinical trial human clinical trial
Fisher CJ et al.Treatment of septic shock with the tumot necrosis factor receptor.Fc fusion protein .N Engl J Med 1996;334:1697-702
Most widely known and used Most widely known and used immunotherapyimmunotherapy Blunt & potent anti-inflammatory Blunt & potent anti-inflammatory Action :Action :
Prevent complement activationPrevent complement activation inhibit nitrous oxide synthataseinhibit nitrous oxide synthatase Decrease proinflammatory cytokinesDecrease proinflammatory cytokines inhibit neutrophil aggregation inhibit neutrophil aggregation stabilise lysosomal membrane stabilise lysosomal membrane
SteroidsSteroids
1960-90S No advantage 1960-90S No advantage 1997 increase mortality with high dose1997 increase mortality with high dose Beneficial for patient with adrenal Beneficial for patient with adrenal insufficiencyinsufficiency Currently “ 2Currently “ 2ndnd generation trials” : generation trials” :
- low & physiological dose- low & physiological dose - long duration- long duration - vasopressor dependant pt- vasopressor dependant pt - no difference among corticotrophic - no difference among corticotrophic dependant or non dependantdependant or non dependant
Minneci PC et al Meta analysis:the effect of steroids on survival & shock during sepsis depend on the dose. Ann Intern Med 2004;141:47-57
Inhibit thrombin and factor Xa Inhibit thrombin and factor Xa
low during sepsis d/tlow during sepsis d/t
- impaired synthesis - impaired synthesis
- consumption by DIC- consumption by DIC
- degradation by elastase- degradation by elastase
Abraham E et al.Efficacy and safety of tifacogen in severe sepsis: randomised controlled trial .JAMA 2003;290:238-47
APC actionAPC action
Anticoagulant
Anti-inflammatory
inhibit transcription NF-kB reducing pro-inflammatory cytokines
APC inactivate Va,VIIa
Low level in sepsis
cytokine-induced down-regulation of thrombomodulin
Esmon CT. Inflammation & thrombosis : mutual regulation by protein C. Immunologist 1998;6:84-89
48hrs /reduces mortalityiv 24 ug/ kg/hr x 96hrs
Recombinant APC “ Dotrecogin alfa” :
- Significant reduction of mortality
- faster resolution cardiovascular &
respiratory dysfunction PROWESS ( protein c worldwide evaluation in severe sepsis)
multicentre study,2001
APCAPC
Vasopressor/ InotropicsVasopressor/ Inotropics
The Surviving Sepsis guidelines The Surviving Sepsis guidelines recommendedrecommended
dopamine or norepinephrine as first dopamine or norepinephrine as first line agents.line agents.
Vasopressin should be considered an Vasopressin should be considered an important adjunct vasopressor.important adjunct vasopressor.
Epinephrine may be considered as a Epinephrine may be considered as a second line agentsecond line agent. .
Matthew C. Byrnes, MDa,b,*, GregJ. Beilman, MDa
INTENSIVE INTENSIVE GLUCOSEMANAGEMENTGLUCOSEMANAGEMENT
Current international recommendations Current international recommendations have been made to maintain blood have been made to maintain blood glucose levels lower than150 mg/dL.glucose levels lower than150 mg/dL.
Maintenance of blood glucose between Maintenance of blood glucose between 80 and 110 mg/dL may carry a 80 and 110 mg/dL may carry a significant risk of hypoglycemia.significant risk of hypoglycemia.
All of the mentioned immunotherapeutic strategies worked in animal models of sepsis but not always converted into patient
Comorbidity Extreme ages organ dysfunction genetic polymorphism site of infection
cautious multi-centre studies !
- differences resources
- availability of intensive care bed
Only APC has been shown to improve outcome in septic patient
low steroid dose also worthy , should not restricted to corticotrophin hypo-responsive patient
Sprung CL et al.Influence of alterations in foregoing life sustaining treatment
practices on a clinical sepsis trial.Critical Care Medicine 1997;25:383-7
most effective management of septic patient remains recognition support of organ dysfunction
antibiotics remain the cornerstone of management
PERITONITIS
ClassificationClassification
1.1. Primary peritonitisPrimary peritonitis
2.2. Secondary peritonitisSecondary peritonitis
3.3. Tertiary peritonitisTertiary peritonitis
Secondary peritonitis is the most
common form for surgeons
Intra-abdominal sepsis...Intra-abdominal sepsis...
DiversionDiversion NutritionNutrition Fluid & ElectrolytesFluid & Electrolytes ABGABG AntibioticsAntibiotics
DiversionDiversion
Small Bowel : ileostomySmall Bowel : ileostomy Large bowel : colostomyLarge bowel : colostomy
More important than More important than antibioticsantibiotics
NutritionNutrition
Enteral or parenteral (TPN)Enteral or parenteral (TPN)
ANY QUESTION?