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Soft Tissue and Surgical Site Infections

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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
тАв Soft Tissue Infections (STI)
тАв Bacteria
тАв Surgical Site Infections (SSI)
Soft Tissue Infections
тАв Diverse group of
diseases involving
the skin and
underlying
structures
Soft Tissue Infections
Meleney Ulcer
Soft Tissue Infections
Classification
Superficial
Deep
Classification
тАв Nonnecrotizing
infections involve
superficial structures
generally
тАв Necrotizing
infections involve
deep structures
generally
Symptoms
тАв Range from
subtle/nonspecific to
obvious
тАв Common findings
тАУ
тАУ
тАУ
тАУ
тАУ
Pain
Edema
Erythema
Tenderness
Warmth
Diagnosis
тАв Host factors
тАв Environmental
factors
тАв Specific clinical
scenarios
тАв Host Factors
Environmental
тАв тАвSpecific
Scenarios
тАУ COPD
factors
тАУ Bites
тАУ Cardiac Disease
тАУ тАвCuts,
тАУAnimal
CHFlacerations
тАУ тАвInjection
тАУHuman
PVD sites
Bites
тАУ тАУChronic
skin disease
тАУ Diabetes
тАУ тАвSkin
diseases
тАУUlcers
Steroids
тАУ тАУWater
exposure
Ulcers
тАУ Immune
Saltwater:
V. vulnificus
Compromise
тАУ тАвSurgical
Incisions
тАвтАУFreshwater:
A. hydrophila
Malnourishment
Necrotizing Infections
тАв Signs/Symptoms
тАУ Pain out of
proportion to exam
тАУ Systemic toxicity
тАУ Ischemic tissues
тАУ Crepitus
тАв Laboratory
тАУ Leukocytosis
тАУ Hyponatremia
Necrotizing Infections
Laboratory Studies
тАв Blood cultures
тАУ
тАУ
тАУ
тАУ
Unusual organism
Refractory cellulitis
Facial involvement
Water exposure
тАв CBC
тАв Lytes
тАв CK levels
Laboratory Studies
тАв Necrotizing STI
тАУ WBC > 15.4 and
sodium < 135
predictive of
necrotizing STI
тАУ WBS < 15.4 and
sodium > 135 had
negative predictive
value of 99%
Imaging Studies
тАв X-ray
тАУ 15-30% demonstrate
gas
тАв CT
тАУ More sensitive than
x-ray
тАв MRI
тАУ Preferred
MRIimaging
modality
Diagnostic Algorithm
Treatment Superficial STI
тАв Superficial
тАУ Mainly
тАв Antibiotics
monomicrobial
тАУ Dicloxacillin
aerobes
тАУтАУ Cephalexin
Staphylococcus
тАУ Erythromycin
aureus
тАУтАУ Clindamycin
Streptococcus
pyogenes
Treatment Superficial STI
тАв Immune Compromise
тАв Scenario specific
тАУ Immune
compromised
тАУ Bites
тАУ Water exposure
тАУ Ulcers
тАУ H influenza
тАУ S epidermidis
тАв Animal Bites
тАУ P multocida
тАв Seawater/Raw Seafood
тАУ V vulnificus
тАв Freshwater
тАУ A hydrophila
Treatment Deep STI
тАв Resuscitation
тАв Physiologic support
тАв Broad spectrum
antibiotics
тАв Debridement
тАв Supportive care
тАвтАв Resuscitation
Broad Spectrum
тАУ Isotonic IV
fluids
Antibiotics
тАв Supportive
care
тАвтАв Debridement
support
тАУ
Adjuncts
тАУNutritional
Polymicrobial
тАУPhysiologic
support
тАУ
The
critical
step
тАвConsider
Foley
тАУ infection
failure
(70-75%)
тАвRenal
postpyloric
тАвfeedings
Central
lines
Reexploration
тАУ Group
Metabolic
acidosis
тАУтАУ
A Strep
тАв PA catheters
mandatory
тАУ тАУCoverage
of defect
common
(90%)
Septic shock
тАУ
тАУ Electrolyte
Anaerobes correction
тАв Hyponatremia
тАУ Gram negative rods
тАв Hypocalcemia
тАв Hyperglycemia
Surgical Debridement
тАв Time from onset of
symptoms to initial
debridement critical
тАУ < 25 hours: 71%
survival
тАУ > 40 hours: 29%
survival
тАУ Clostridial
myonecrosis: no
survival if surgery
delayed 48 hours
Antibiotic Choice
тАв Penicillin/Ampicillin
тАУ Eagle effect
тАв Clindamycin
тАв Consider
aminoglycoside
тАв Consider Imipenem
Mortality
тАв Reifler et al, 1988
тАУ Limited debridement:
71% mortality
тАУ Radical
debridement: 43%
mortality
тАв Overall
approximately 30%
тАв 63% of deaths due
directly from the
infection in first
week
тАв 37% due to multiple
system organ failure
latter
Synergy of Polymicrobial
Infections
тАв Seal and
Kingston,1988
тАУ GAS: 12% spread
тАУ GAS and S. aureus:
50% spread
тАУ GAS and a-lysin:
75% spread
Clostridium Exotoxins
тАв a-toxin
тАУ Cell membrane
destruction
тАв q-toxin
тАУ WBC inhibition
тАв Other toxins
тАУ Platelet aggregation
Streptococcal Toxins
тАв M proteins
тАУ Prevent
phagocytosis
тАУ Induce vascular leak
тАУ Cleave NAD
тАв SPE
тАУ Induce inflammatory
cytokines
Superantigens
Surgical Site Infections
тАв 3rd most common
nosocomial infection
(14-16%)
тАв Increase cost and
length of stay
тАв Most common
nosocomial infection
on surgical services
Surgical Wound Infection Task
Force
тАв 77% of deaths with
тАв 60-80% of infections
nosocomial
involve the incision
infections present
тАв 20-40%
of infections
due to infection
involve the deep
тАв 93% of these
spaces accessed or
infections involved
organs operated
organs or spaces
upon
accessed during
surgery
Pathogenesis
тАв Host factors
тАв Inoculum size
тАв Length of operation
Host Factors
тАв
тАв
тАв
тАв
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)
тАв Atraumatic wound
without inflammation
тАв Do not enter GI, GU,
biliary, or respiratory
tract
тАв 1.5% infection rate
Class II Wound
(Clean-Contaminated)
тАв Respiratory, GI, GU,
or biliary tract
entered under
controlled conditions
тАв 7.5% infection rate
expected
Class III Wounds
(Contaminated)
тАв Traumatic wounds
тАв Breaks in sterile
technique
тАв Gross spillage from
GI tract
тАв Acute, nonpurulent
inflammation
тАв 15% anticipated
infection rate
Class IV Wounds (Dirty)
тАв Old traumatic
wounds
тАв Devitalized tissue
тАв Clinical infection
present
тАв Perforated viscus
тАв 40% expected
infection rate
SENIC Risk Index
тАв Abdominal operation
тАв Operation greater
than 2 hours
тАв Class III or IV
surgical wounds
тАв 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
score
above disease
2
2тАв ASAMild
systemic
of
3тАв Level
Severe
systemic disease
contamination
4
Life threatening systemic disease
тАв 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
1
2
Clean
1.0%
2.3%
5.4%
Clean
Contaminated
2.1%
4.0%
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
тАв Superficial soft tissue infection
тАУ Generally monomicrobial aerobic gram
positives
тАУ DonтАЩt forget specific scenarios for unusual
organisms (ex: ulcers, water exposure)
тАв Deep soft tissue infections (necrotizing)
тАУ Polymicrobial is the norm
тАУ Rapidly fatal without surgical intervention
Summary
тАв Polymicrobial infections display synergy
from toxin production
тАУ Affect vascular supply, cause cell
disruption, and inhibit immune response
тАУ Virulent strains of Group A Streptococcus
and Clostridial sp. extremely effective at
these functions
Summary
тАв Surgical site infections are a definite
problem in health care
тАв Factors involved in surgical site
infection development
тАУ Host factors
тАУ Inoculum size
тАУ Length of operation
Summary
тАв Discussed several risk stratification
schemes
тАУ Surgical Wound Classification
тАУ SENIC index
тАУ NNIS risk index
тАв Prophylactic antibiotic choice
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