What is new in management of Surgical Infection Prof. Ravi Kant

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


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.


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


PulmonaryPulmonaryPneumoniaPneumonia

Non-ventilator associatedNon-ventilator associated

Ventilator associatedVentilator associated

AspirationAspiration


Urinary TractUrinary TractDiagnosisDiagnosisUsual suspectsUsual suspects

Pseudomonas, Serratia, Pseudomonas, Serratia, other other


Foreign-body associatedForeign-body associatedSitesSites

CathetersCathetersLinesLinesProsthetics/graftsProsthetics/grafts


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


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


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


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



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


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;


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.



Mortality was significantly lower among patients randomized to EGDT (48.2% versus

33.3%, P 5 .01).


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?

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What is new in management of Surgical Infection Prof. Ravi Kant