Surg Med - Surg Infxn + Fever - Exam 1

Clean Wound

Uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered

1-2% infection rate

Clean/Contaminated Wound

Operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination

5-10% infection rate

Contaminated Wound

Open, fresh, accidental wounds, operations with major breaks in sterile technique or gross spillage from the GI tract, and incisions in which acute, nonpurulent inflammation is encountered

15-20% infection rate

Dirty Wound

Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera

> 30% infection rates

Superficial Incisional Site Infxn

Skin, subcutaneous tissue of the incision

Deep Incisional SSI

Fascial, muscle layers of the incision

Organ/Space SSI

Generalized: any part of the body deeper than the facial/muscle layers that is opened or manipulated during the procedure (peritonitis)

Abscess: walled off collection

Surgical Site Infxn S/S

Pain or tenderness

Swelling

Erythema

Warmth

Purulent drainage

Dehiscence

Fever or chills

SSI Etiology

Staph aureus (MRSA)

Streptococcus

Klebsiella pneumoniae

E. coli

Enterococcus species (VRE)

Pseudomonas aeruginosa

SSI Tx

Superficial infection: bedside opening of incision, exploring, irrigating, debridement

Deep/organ space: return to OR for exploration, washout, drainage, and debridement

Implants are often removed

SSI Prevention

ABX prophylaxis

Given 30 min - 1 hour prior to starting surgery

Cefazolin 2 g q 4 hours

Surgical Abscess

Infectious accumulation of purulent material in a closed cavity

Skin Abscess

Dermis/subcutaneous space

Painful, fluctuant, erythematous nodule with or without surrounding cellulitis

Treatment: I & D

Peritoneal Abscess

Collection of pus resulting from hematogenous, lymphatic, or contiguous spread of infection

CT preferred imaging

S/SX: Flank pain, Fever, Abdominal pain

Treatment: Percutaneous drainage and ABX

Skin Flora (strep, Staph)

What are the common pathogens for surgical abscesses?

Abx (bactrim, clinda, vanc)

what is the treatment for a surgical abscess?

Necrotizing Skin and Soft-Tissue Infections

Cause widespread and severe tissue necrosis resulting from aggressive and life-threatening bacteria that are often able to secrete toxins

Usually the result of a traumatic wound with vascular compromise

Deep, penetrating wounds that create ideal anaerobic environment

NSTIs - Causative Agents

Type I: monomicrobial 

-Streptococci, clostridia

Type II: polymicrobial

-Mixed flora anaerobic & aerobic

Type III: vibrio vulnificus (rare) found in salt water

NSTIs RF

Immunocompromised

IV drug use

Cancer patients

Malnourished

DM

Obesity

NSTIs S/S

Fever

Pain out of proportion to exam

Erythema

Induration

Bullae

Dark/golden discoloration

Gray tissue

"Dishwater-like" discharge

Systemic signs of progression: hypotension, tachycardia, electrolyte imbalances, lethargy, organ failure

NSTIs - Tx

Surgical emergency → wide surgical debridement + 2 broad spec ABX + antifungals

Pseudomembranous Colitis

Superinfection

Overgrowth of C. diff secondary to use of broad-spectrum ABX

Diagnosis: Stool culture

Tx: D/C of causative ABX, IV metronidazole, PO vancomycin or Fidaxomicin

Pseudomembranous Colitis Prevention

Enteric feeds

Probiotics

PPI

Carafate

Post-Op Pneumonia

MC pulmonary complication among patients who die after surgery

Mortality 20-40%

Atelectasis, aspiration, and copious secretions are predisposing factors

Post-Op Pneumonia Pathogens

Strep Pneumo

Staph aureus

Pseudomonas, Klebsiella (ventilators → ICU pneumonia)

Resistant Pneumococcus

Post-Operative Pneumonia

Fever

Tachypnea

Increased secretions

Signs of pulmonary consolidation

Urinary tract infections

Typically due to Foley catheter: Bacteria present in about 5% of patients with Foley < 48 hours

Usually does not lead to sepsis unless it is an upper UTI

Make sure to send culture with UA

Treatment: ABX, removal of associated catheter

Central Line-associated bloodstream infections (CLABSIs)

Contaminated central line

S/SX: Fever/chills, Hypotension/sepsis in severe cases

Pathogens Enterococcus MC, Coag. negative Staph, Candida

CLABSIs Tx

Removal

Culture intracutaneous portion & IV tip

Empiric broad-spec IV ABX (vanc + gram negative coverage)

CLABSIs Prevention

Sterile insertion

Hand hygiene before any line manipulation

Daily review of necessity

As few lumens as necessary

Superinfection

Normal microbiota keeps opportunistic pathogens in check

Broad-spectrum ABX kill nonresistant cells

Drug resistant pathogens proliferate and can cause a superinfection

Post Op Fever Causes

Atelectasis: Post-op day 1-2

UTI, pneumonia, phlebitis: Post-op days 3-5

Wound infection, anastomotic breakdown, intra-abdominal infection, DVT: Post-op days 5-7

Drug reaction, transfusion reaction, bacteremia: Anytime