Surgical infecton

(Surgical infection). (Surgical Site Infection, SSIs)

.. 2535 Centers for Disease Control and Prevention (CDC) wound infection surgical site infection(1) (, ) ( ) (1) SSI 1.4(2) 60(3) 60-90(4) 50 1 1 (flora) Staphylococcus aureus (5) Staphylococcus Enterococcus Escherichial coli (clean-contaminated) (contaminated) E. coli Enterobacteriaceae 7

1 ( Horan TC et al. Am J Infect Control 1992; 20: 271-4.) (1)

SSI 1. 2. 3. 3 X =

(toxin) Klebsiella Streptococcus pneumoniae phagocytosis endotoxin lipopolysaccharide clostridia streptococci exotoxin 3 2 24 105 SSI (6-7) 4 (1) (clean wound) (clean-contaminated wound) (contaminated wound) (dirty or infected wound) 1-5, 3-11, 10-17 27 1

(clean)

(clean-contaminated)

(contaminated)

(dirty/infected) (peritonitis) (debridement, necrosectomy)

(8) FiO2 80 (9-11) (80-110 mg%) 48 . (12-14) 150 mg% 200 mg% CDC National Nosocomial Infection Surveillance (NNIS) 1 1. 75 2. 3. American Society of Anesthesiologists score (ASA) 2 1 ( 2) 2 NNIS(15-16) ()

75 (+1 )01.5-3.95

(+1 )1

ASA 2 (+1 )26.8-22.08

(-1 )313.0-37.23

1. (aseptic and antiseptic) 2. (prophylactic antibiotics) 3. (surveillance programs) (exogenous) (endogenous) 4% chlorhexidine gluconate (Hibiscrub) (17-18) (19) spores providone-iodine chlorhexidine 2-3 providone-iodine, chlorhexidine alcoholic hand-rub solutions(20) 2 (21) 40-60 25-50 30-60 1 1-2 1-2 24 Bacteroides species cefatetan, cefoxitin ceftriaxone metronidazole anaerobic cefazolin MRSA (methicillin resistant S.aureus) vancomycin (21) (22) (23,24) mechanical cleansing neomycin erythromycin metronidazole 19, 18 9 (25) osmotic agent swiff solution penrose phagocytosis 3-5 albumin immunonutrition (arginine, nucleotides, omega-3 fatty acids) (cellulitis and abscess) (fluctuation) (ultrasound) (CT scan) Staphelococcus aureus streptococci anaerobic cloxacillin penicillin erythromycin aminoglycoside cephalosporin 3 clindamycin metronidazole 6 1 . 5 (necrotizing soft tissue infection) gram stain clostridium (clostridial myonecrosis) necrotizing fasciitis (gas gangrene) clostridium E.coli (anaerobic metabolism) 2 clostridium C.perfringens, C.novyi, C.septicum clostridium . hemolytic S. pyogens (compartmental syndrome) fasciotomy amputation split thickness skin graft (intraabdominal and retroperitoneal infection) 20(26) 50 APACHE (acute physiology and chronic health evaluation) 10 3 E.coli, Enterococcus spp, Streptococcus spp, Bacteroides spp. cefoxitin, cefotetan, ticareillin/clavulanate, ertapenem, ampicillin/sulbactam imipenem, meropenem, piperacillin/tazobactam MRSA, VRE beta lactam-resistant enterococci vancomycin (27) Candida Candida 1 fluconazole

fibrin retroperitoneal retroperitoneal APACHE II 25 recombinant human activated protein C (26) (prosthesis device related infection)

polymorphonuclear Staphylococcus epidermidis (urinary tract infection) (pneumonia) (new infiltration) crepitation bronchoalveolar larvage (pneumonia associated ventilator) (peripheral and central catheter) complete blood count 3 (microatelectasis) 5 5 36 (tachycardia) necrotizing fasciitis, S.aureus toxic shock syndrome exotoxin Staphylococci, Streptococci staphylococci 2 coagulase positive S. aureus coagulase negative S. epidermidis S. aureus penicillin (MRSA) endocarditis MRSA vancomycin coagulase negative staphylococci coagulase negative staphylococci methicillin

streptococci penicillin streptococci group D (enterococci) subacute bacterial endocarditis enterococci gentamicin ampicillin vancomycin enterococci 2 (VRE) cephalosporin 3 vancomycin Enterobacteria, Escherichia, Proteus Klebsiella cephalosporin 3 aminoglycoside Enterobacter, Morganella, Providencia, Serratia, Pseudomonas Acinetobacter ceftazidium, cefepime, aztreonam, imipenem/cilastatin, meropenam, ciprofloxacin Acinetobacter atreonam Pseudomonas carbapenems Bacteroides fragilis metronidazole, clindamycin, chloramphenicol, imipenem, meropenem ertapenem

clostridium C. difficile C. tetani (TAT) (TT) Candida nystatin ketoconazole candida amphotericin 3-5 /. 10-14 candida albicans fluconazole cytomegalovirus HIV (universal precaution) minimum inhibitory concentration (MIC) 2-3 7-14 48 ceftriaxone, cefotaxime

(superinfection)

2-10 C. difficile vancomycin C. difficile pseudomembranous metronidazole vancomycin metronidazole (antibiotic resistance)

2 1. (intrinsic) vancomycin 2. (acquired) 2.1 pseudomonas enterobacteriaceae -lactams

2.2 (neutralization) -lactam -lactamases 2.3 pneumococcus penicillin MRSA -lactam

2.4 plasmid () () 200 mg% FiO2 80 (References)

1. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG. CDC Definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Am J Infect Control 1992; 20: 271-4.

2. Kasatpibal N, Jamulitrat S, Chongsuvivatwong V. Standardized incidence rates of surgical site infection: a multicenter study in Thailand. Am J Infect Control 2005; 33: 587-94.

3. de Oliveira AC, Ciosak SI, Ferraz EM, Grinbaum RS. Surgical site infection in patients submitted to digestive surgery: risk prediction and the NNIS risk index. Am J Infect Control 2006; 34: 201-7.

4. Gaynes RP, Culver DH, Horan TC, Edwards JR, Richards C, Tolson JS et al. Surgical site infection (SSI) rates in the United States, 1992-1998: the National Nosocomial Infections Surveillance System basic SSI risk index. Clin Infect Dis. 2001; 33: S69-77.

5. Cantlon CA, Stemper ME, Schwan WR, Hoffman MA, Qutaishat SS. Significant pathogens isolated from surgical site infections at a community hospital in the Midwest. Am J Infect Control. 2006; 34: 526-9.

6. Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2006; 3: CD004122.

7. Tanner J, Moncaster K, Woodings D. Preoperative hair removal: a systemic review. J Perioper Pract. 2007; 17: 118-21, 124-32.

8. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996; 334: 1209-15.

9. Kabon B, Nagele A, Reddy D, Eagon C, Fleshman JW, Sessler DI et al. Obesity decreases perioperative tissue oxygenation. Anesthesiology 2004; 100: 274-80.

10. Belda FJ, Aguilera L, Garcia de la Asuncion JG, Alberti J, Vicente R, Ferrandiz L et al. Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA. 2005; 294: 2035-42.

11. Chura JC, Boyd A, Arqenta PA. Surgical site infections and supplemental perioperative oxygen in colorectal surgery patients: a systematic review. Surg Infect. 2007; 8: 455-462.

12. Ambiru S, Kato A, Kimura F, Shimizu H, Yoshidome H, Otsuka M et al. Poor postoperative blood glucose control increases surgical site infections after surgery for hepato-biliary-pancreatic cancer: a prospective study in a high-volume institute in Japan. J Hosp Infect. 2008; 68: 230-3.

13. Vilar-Compte D, Alvarez de Iturbe I, Martin-Onraet A, Perez-Amador M, Sanches-Hernandez C, Volkow P. Hyperglycemia as a risk factor for surgical site infections in patients undergoing mastectomy. Am J Infect Control 2008; 36: 192-8.14. Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project. Endocr Pract. 2004; 10: 21-33.

15. Dominioni L, Imperatori A, Rotolo N, Rovera F. Risk factors for surgical infections. Surg Infect 2006; 7: S9-12.

16. Inigo JJ, Bermejo B, Oronoz B, Herrera J, Tarifa A, Perez F et al. Surgical site infection in general surgery: 5-year analysis and assessment of the National Nosocomial Infection Surveillance (NNIS) index. Cir Esp. 2006; 79: 224-30.

17. Lynch W, Davey PG, Malek M, Byrne DJ, Napier A. Cost-effectiveness analysis of the use of chlorhexidine detergent in preoperative whole-body disinfection in wound infection prophylaxis. J Hosp Infect. 1992; 21: 179-91.

18. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. 2007; 2: CD004985.

19. Edwards PS, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev. 2004; 3: CD003949.

20. Tanner J, Swarbrook S, Stuart J. Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst Rev. 2008; 1: CD004288.

21. Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database Syst Rev. 2006; 3: CD003087.22. Cunningham M, Bunn F, Handscomb K. Prophylactic antibiotics to prevent surgical site infection after breast cancer surgery. Cochrane Database Syst Rev. 2006; 2: CD005360.23. Pessaux P, Atallah D, Lermite E, Msika S, Hay JM, Flamant Y et al. Risk factors for prediction of surgical site infections in "clean surgery". Am J Infect Control. 2005; 33: 292-8.24. Pessaux P, Lermite E, Blezel E, Msika S, Hay JM, Flamant Y et al. Predictive risk score for infection after inguinal hernia repair. Am J Surg. 2006; 2: 165-71.25. Guenaga K, Atallah AN, Castro AA, Matos DDM, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev. 2005; 1: CD001544.26. Pieracci FM, Barie PS. Intra-abdominal infections. Curr Opin Crit Care. 2007; 13: 440-9.27. Dupont H. The empiric treatment of nosocomial intra-abdominal infections. Int J Infect Dis. 2007;11: S1-6. (Suggest Reading)1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999; 20: 247-78.

2. Anaya AD, Dellinger EP. Surgical infection and choice of antibiotics. In: Townsend MC, Beauchamp RD, Evers BM, Mattox LK, eds. Sabiston textbook of surgery: the biological basis of modern surgical practice. 17th ed. Philadelphia: Elsevier Saunders, 2004; 257-82.

3. Dunn LD, Beilmn JG. Surgical infections. In: Brunicardi FC, Andersen KD, Billiar RT, Dunn LD, Hunter GJ, Pollock ER, eds. Schwartzs principles of surgery. 8th ed. New York: McGraw-Hill, 2005; 109-27.

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