Most dreaded problems surgeons presented with o Requires surgical treatmet o Something that is caused by surgical problem initially or post-op; it appears from some reason or another Classification Clean Wound o Don't expect any problems with pt post op; do not have any infection; o Non traumatic; no break in the technique - sterile technique where everything has to be clean has not broken; nothing fell on the floor; anyone who touches instrument also aseptic No break in Git tract o Don't operate on urinary, GIT, respi tract Thyroid operation - above traches Operate on it; don't have to enter the trachea; nothing else disturbed but the thyroid So don't expect infecion in theses pts post operatively Clean Contaminates o Git, respi, uro tract has been entered o Low post op infections 1-1.5 % (initiially) 3-5% o o o Minimal spillage Gallbladder Elective will not have bile infection But we give antibiotics pre op Might expect wound infection ---quite rare (3-5%) Early appendectomy Congested appendix --still clean contaminated Contaminated Wound > 5-10% o Major break in technique o Break in presence of infected fluids o Acute consistitis Bile is infected Dirty Wound o With dead, devitalized tissue o Fecal material may have spilled o Perforated viscus - close it up to fascia, leave subcutaneous and skin layer open (delayed closure) o 10-15% infection o Ruptured colonic o Abscisses We categorize our patients because it's for us to know whether to give antibiotics or not pre-op o Elective surgery Clean - don't expect infection post op So don't give antibiotics pre and post operatively Example - thyroid, breast surgery, excision biopsies in skin; all are clean from start; no infections; inspect to use sterile instruments Clean Contaminated and Contaminated Already have an infection pre-op Clean - Give antibiotic (prophylactic) - don't want infection in that organ to spread to the wound (incision site); so give pre-op antibioticd (double the usual dose); give about an hour prior to surgery so tissues have adequate dose by surgery Congested appendicitis, acute colonocitis Clean Contaminated - 750 mg (usual dose) For pre op -- double dose -- 1.5 gms Post op --give 750 mg for 3 more doses or for one more day Removal of organ during surgery plus antibiotic -- pt safe from infection Contaminated Give a pre-op antibiotic It's good because sometimes when have contaminated, antibiotic may transform contaminated organ into clean-contaminated organ; bit safer Also give antibiotics for 24 hours Dirty wounds Already dirty Preop antibiotics - same dose/time Give it for 7 days Not prophylactic anymore But therapeutic antibiotics - gross contamination, spillage, contamination; have to treat the infection o o Wound Prevention aside from Antibiotic administration o Avoidance of bacterial contamination If instruments, room, gloves is contaminated with bacteria, no matter how clean surgery is, you'll have post op surgery infection o Avoid exogenous/endo contamination From the pt himself and from outside (nurses, dr) = they should all be clean; don't let anyone with pneumonia in the operation room o Use of UV light and laminar flow Uv light - used for water - bacteria will go to the pipes Grossly contaminated surgery - don't just clean OR with acid; use UV light to kill anymore remaining bacteria Laminar flow -- one unidirectional air flow going out; don't get airconditioner that gets air outside going in - Inundation of traffic from in to out of OR When surgery done, expect 20 people inside; surgeons; 10 clerks, 10 nursing students; o Limitation of talking and activity Wear masks to protect the pt also o o Pre Op preparation Pre op shower; if stab wound, maybe not If elective surgery, ask pt to take a shower the night before Cutaneous infection Should be controlled Cellulitis o Hair removal Injury of shaving may promote bacterial growth Initially done night before surgical procedure; it can promote cuts in the skin; pt brought in OR - the next morning will bring all the bacteria he got in the ward Now - 1hr prior to surgery; shaving done in OR Use a depulator - pulls out the hair o Skin prep Scrub area for 5-7 minutes with solution Paint with povidone-iodine (soap and disinfectant are different) Works within 45 seconds upon applying In ER, can be done in 1 minute Use anti-microbial incision tape Exclusive type of tape - place it all around areas you plan to operate on Drape with a hole in the center; borders have a tape which sticks to the skin; barrier from the outside skin Wear clean scrub suits Cap and mask Gown, cap, mask and goggles used now Not just for pt to protect dr's from pts but to protect doctors from patients with all airbourne diseases Bare hand operations Pt will not get infections Without cap/mask, without drape, gown Alcohol solution --rinsing not required anymore 30 seconds Scrubbing only done in 5 minutes o o o o o Make sure drapes are clean - don't let it drag on sides of bed or other parts of OR Change punctured/torn gloves 20% of all surgeons after surgery had a punctured glove Didn't know about it - just continued; nothing happened to patient, but the doctor was contaminated Avoid contamination of surgical wound at time of transection Colon - how do you protect sides of the wound Use operating sponges that you put around border of incision to protect the sides of wound - to prevent bile spillage; if it spills, sides will be protected by the sponges Diagnosis of Wound Infection o o o Redness, swelling, heat, pain, loss of function, fever and chills Appendectomy On the 3rd post op day, send pt home Ask them to come back after 7 days from time of surgery Most of the time, surgery successful Pt comes back walking straight If he's bent over holding side, inspect wound has become infected; very painful -- already puss underneath the skin --- so you have abscess (in the teeth - have it pulled, in the arm, anywhere in the body) ---very painful Only way to relieve pain is to open up the wound and let the abscess (puss) out Causes of wound infection Should be enough of bacteria there; 1 or 2 won't cause contamination Won't grow because your inherent antibodies will be able to destroy the bacteria If 100 thousand there, host defenses (neutrophils, macrophages) are overwhelmed o Position and growth of No bacteria, no infection o Type and number If you have staph epidermidis in the wound, most likely no infection If you have staph aureus, strep, then you Will get infection Number Have hemolytic staph/strep If 1000 present, will not get infection If 100,000, you will get infection o Surface Component Factors in the bacteria itself that prevent them from being destroyed by immune system Endotoxin In gram negative bac eColi - found in all organs in the body (GI tract); if overgrowth of eColi, then infection Lipopolysaccharides - makes the bacteria slippery so that macrophages cannot engulf them; difficult to destroy Exotoxin Gram positive Bact contamination > 100,000 cause infection Local Wound factors Inhibition of local defense for clearing bacteria out Blood supplies - if it's destroyed in that area Burns - good chance that area will be contaminated/infected later on o Bette blood supply, better defense Of skin, What layer has the poorest blood supply? o Subcutaneous fat -- gets most infected Bears the brunt of any infection o Skin - good blood supply o Muscles - excellent blood Rare infections o Peritoneum - good blood supply Inhibition of phagocytic cells to directly contact and kill the bacteria o Diabetes (uncontrolled) Ability of own macrophages to attach themselves to bacteria is diminished; Macro unable to grasp, engulf and destroy them Phagocytosis is inhibited Once you control diabetes, infection rate is controlled as normal Patient Factors Age, reduction in blood flow, vascular reactivity, malignancy or trauma o Age (very young or old) Have very incomplete/poor immune system o Reactivity Ability to bring in macrophages o Malignancy or trauma Increase wound infection o Anemia Will not increase the infection rate Hemoglobin rate of 7 or 8 Not known why Doesn't interfere with the immune system o Malnutrition Surgical techniques o Don't avulse tissues o All dead tissues and foreign bodies should be removed Sources for infection Debridement - process name o Use of monofilament sutures for infected wounds Monofilament suture - made of one strand braded suture - 5 or 6 intertwined sutures; bacteria hiding within braded spaces that were not accessible to the antibiotics; Monofilament advocated - the bacteria was hiding in the interplane sutures One suture - can't hide Proline, thymine o Avoid hematomas, seromas and dead space High in protein Agar plates - where bacteria grow and thrive in Dead space - you took out a lump beneath skin; skin is loose; if you close skin, there's a space where lump used to be; space where seroma will grow -- it will let the bacteria proliferate Systemic Factors o Host resistance o Malnutrition o Avoid usage of so many drugs; post-op, avoid the drugs o Advocate the use of 1 antibiotic only for any infection; sometimes you hear pt give 3-4 antibiotics for pneumonia; 1 advocated only How will you know which antibiotic to use Get culture and sensitivity of that wound Waith 3-5 days In the meantime, use antibiotic Ecoli --give 2nd generation Then use particular antibiotic that has been specified by the test Sometimes amoxycillin is the simple drug that you only have to use o Systemic Prophylactic Chemo and Antibiotics All antibiotics have a side effect; PINS -phil index of … List of all drugs available in country with dosage, prep, tablet, id Side effects at the bottom (contraindicator) Have to weigh benefit of that drug against adverse effects Drug may cause an abortion Shotgun therapy - pt comes in, fever == don't know exact cause; you give 3 drugs One for gram positive, negative and .. Shotgun not used -- will kill all bacteria; will also kill beneficial bacteria especially in the colon causing a superinfection Colitis - indiscrimate use of drugs cause infection; all beneficial bac in colon destroyed followed by powerful infection caused by claustridium … If you use 2nd/3rd generation antibiotics, some bacteria is already resistant to it, so you have to give an entirely new antibiotic for it to work Good time to do blood workup Not done for 2-3 days When you get culture sensitivities back, then you get antibiotics By 3-4 day, you should have diagnose already Secondary or superimposed infection Hypersensitivity reaction If have 5 drugs in that pt and he develops reaction, you don't know which of the 5 drugs caused it Mask signs and symptoms of infection Not only infection causes problem Obstruction Acute appendicitis o o 15 yr old pt -- right quadrant pain Vague pain - came in 6 hours from onset of pain (epigastric) Ultrasound will not help diagnosis CBC normal; neutrophils rising No fever Slight anorexia, no vomiting -everything still vague Don't operate yet in pt. Usually tell parents that we will observe pt overnight. Next morning 12 hours later - during observation, don’t' give analgesics or pain will disappear Don't give antibiotics - may mask signs and symptoms of infection Obstruction is still there - appendix still obstruction; antibiotics hasn't stopped it; it superficially took out only If next day, pain progressed ----do surgery If it disappeared Observe longer Do CBC if it went down Development of resistant stains Give antibio --destroyed 90% of bacteria 10% survived and developed resistance; will now proliferate and cause infection Get another antibiotic now; 90% destroyed other 10 resistant -- proliferate again ----continous cycle, never ending Principles of Antibiotic therapy General principle Achieve level of antibiotics at site of infection MIC Minimum inhibitory compensation Need to have enough amt to kill bacteria in that area Can't happen all the time Burn - infected skin; give antibiotics; antibiotics won't reach burned wound because blood supply to the wound is already destroyed If mild infection (sore throat) If signs of sepsis (leukocytosis greater than 12,000, temp > 36, heart rate > 90, respi rate > 20) Only need 2 of 4 to label sepsis Give IV antibiotics When do you stop giving IV antibiotics and shift to oral if obvious improvement is seen If pt had fever and it settled, shift to oral If pt has good bowel movement already, good sign pt is doing well If pt hungry and passed gas, great sign pt is doing well after surgery Can start oral If no improvement in 2-3 days Procedure may not be adequate Live abscess - may not have adequately drained the liver out Complications Superinfections Drug of choice may be correct but insufficently administered Happens a lot; scared to push drug to the limit esp in renal failure - which causes side effects or a different drug maybe needed Continue antibiotics orally No hard and fast true with 7 days No more "take for 7 days" Lots of diseases are now treated by 1-3 day regimen Pneumonia -- 3 day treatment only Drug only 300 pesos Surgeons Before you send pt home, opt for oral intake already for 5 days Imporved mental status Return of bowel function Spontaneous diuresis Superinfection New infection that develops during antibiotic treatment for original infection Psuedomembranous colitis Membrane that covers colon that produces severe diarrhea that causes dehydration Can kill pt fast due to dehydration 2-10% antibiotic treated pt develops superinfection Limit the dose and duration of antibiotic treatment Antibiotics Should be active against infecting organism Adequate contact btw the drug and offending microbe Absence of toxic side effects If you have immunocompromised and he depends on antibiotics to control infection, most likely he will die Can't depend on antibiotics alone;pt should have good immune system to augment antibacterial properties of the drug