Chapter 27 / Surgical Infection 175

When should an abdominal CT scan be obtained looking for a postoperative abscess?

What CT scan findings are associated with abscess?

What is the treatment?

What is an option for drainage of pelvic abscess?

All abscesses must be drained except which type?

NECROTIZING FASCIITIS

After POD #7 (otherwise, abscess will not be “organized” and will look like a normal postoperative fluid collection)

Fluid collection with fibrous rind, gas in fluid collection

Percutaneous CT–guided drainage

Transrectal drainage (or transvaginal)

Amebiasis!

What is it?	Bacterial infection of underlying fascia
	(spreads rapidly along fascial planes)
What are the causative	Classically, group A Streptococcus
agents?	pyogenes, but most often polymicrobial
	with anaerobes/gram-negative organisms
What are the signs/	Fever, pain, crepitus, cellulitis, skin
symptoms?	discoloration, blood blisters (hem-
	orrhagic bullae), weeping skin, increased
	WBCs, subcutaneous air on x-ray, septic
	shock
What is the treatment?	IVF, IV antibiotics and aggressive early
	extensive surgical débridement, cultures,
	tetanus prophylaxis
Is necrotizing fasciitis an	YES, patients must be taken to the O.R.
emergency?	immediately!
CLOSTRIDIAL MYOSITIS
What is it?	Clostridial muscle infection
What is another name for	Gas gangrene
this condition?

176 Section I / Overview and Background Surgical Information

What is the most common	Clostridium perfringens
causative organism?
What are the signs/	Pain, fever, shock, crepitus, foul-smelling
symptoms?	brown fluid, subcutaneous air on x-ray
What is the treatment?	IV antibiotics, aggressive surgical
	débridement of involved muscle, tetanus
	prophylaxis
SUPPURATIVE HIDRADENITIS
What is it?	Infection/abscess formation in apocrine
	sweat glands
In what three locations does	Perineum/buttocks, inguinal area, axillae
it occur?	(site of apocrine glands)
What is the most common	Staphylococcus aureus
causative organism?
What is the treatment?	Antibiotics
	Incision and drainage (excision of skin
	with glands for chronic infections)
PSEUDOMEMBRANOUS COLITIS
What is it?	Antibiotic-induced colonic overgrowth
	of C. difficile, secondary to loss of
	competitive nonpathogenic bacteria that
	comprise the normal colonic flora
	(Note: it can be caused by any antibiotic,
	but especially penicillins, cephalosporins,
	and clindamycin)
What are the signs/	Diarrhea (bloody in 10% of patients),
symptoms?	fever, increased WBCs, abdominal
	cramps, abdominal distention
What causes the diarrhea?	Exotoxin released by C. difficile
How is the diagnosis made?	Assay stool for exotoxin titer; fecal
	leukocytes may or may not be present;
	on colonoscopy you may see an exudate
	that looks like a membrane (hence,
	“pseudomembranous”)

	Chapter 27 / Surgical Infection 177
What is the treatment?	PO metronidazole (Flagyl®; 93% sensitive)
	or PO vancomycin (97% sensitive);
	discontinuation of causative agent
	Never give antiperistaltics
PROPHYLACTIC ANTIBIOTICS
What are the indications for	Accidental wounds with heavy
prophylactic IV antibiotics?	contamination and tissue damage

Accidental wounds requiring surgical therapy that has had to be delayed Prosthetic heart valve or valve disease

Penetrating injuries of hollow intra-abdominal organs

Large bowel resections and anastomosis Cardiovascular surgery with the use of a

prosthesis/vascular procedures Patients with open fractures (start in ER) Traumatic wounds occurring 8 hours

prior to medical attention

What must a prophylactic antibiotic cover for procedures on the large bowel/abdominal trauma/appendicitis?

What commonly used antibiotics offer anaerobic coverage?

What antibiotic is used prophylactically for vascular surgery?

When is the appropriate time to administer prophylactic antibiotics?

Anaerobes

Cefoxitin (Mefoxin®), clindamycin, metronidazole (Flagyl®), cefotetan, ampicillin-sulbactam (Unasyn®), Zosyn™, Timentin®, Imipenem®

Ancef (if patient is significantly allergic to PCN—hives/swelling/shortness of breath—then erythromycin or clindamycin are options)

Must be in adequate levels in the blood stream prior to surgical incision!

178 Section I / Overview and Background Surgical Information

PAROTITIS

What is it?	Infection of the parotid gland
What is the most common	Staphylococcus
causative organism?
What are the associated risk	Age older than 65 years, malnutrition,
factors?	poor oral hygiene, presence of NG tube,
	NPO, dehydration
What is the most common	Usually 2 weeks postoperative
time of occurrence?
What are the signs?	Hot, red, tender parotid gland and
	increased WBCs
What is the treatment?	Antibiotics, operative drainage as
	necessary
MISCELLANEOUS

What is a “stitch” abscess?

Subcutaneous abscess centered around a subcutaneous stitch, which is a “foreign body”; treat with drainage and stitch removal

Which bacteria can be found	Anaerobic—Bacteroides fragilis
in the stool (colon)?	Aerobic—Escherichia coli
Which bacteria are found in	Streptococcus viridans, S. aureus,
infections from human bites?	Peptococcus, Eikenella (treat with
	Augmentin®)
What are the most common	Gram-negative organisms
ICU pneumonia bacteria?
What is Fournier’s	Perineal infection starting classically in
gangrene?	the scrotum in patients with diabetes;
	treat with triple antibiotics and wide
	débridement—a surgical emergency!

Does adding antibiotics to peritoneal lavage solution lower the risk of abscess formation?

No (“Dilution is the solution to pollution”)

	Chapter 27 / Surgical Infection 179
What is the classic	Green exudate and “fruity” smell
finding associated with a
Pseudomonas infection?
What are the classic	Ampicillin, gentamycin, and
antibiotics for “triple”	metronidazole (Flagyl®)
antibiotics?
Which antibiotic is used to	Metronidazole (Flagyl®)
treat amoeba infection?
Which bacteria commonly	Staphylococcus epidermis
infect prosthetic material
and central lines?
What is the antibiotic of	Penicillin G (exquisitely sensitive)
choice for Actinomyces?
What is a furuncle?	Staphylococcal abscess that forms in a
	hair follicle (Think: Follicle Furuncle)
What is a carbuncle?	Subcutaneous staphylococcal abscess
	(usually an extension of a furuncle), most
	commonly seen in patients with diabetes
	(i.e., rule out diabetes)

What is a felon?

What microscopic finding is associated with Actinomyces?

What organism causes tetanus?

What are the signs of tetanus?

What are the appropriate prophylactic steps in tetanus-prone (dirty) injury in the following patients:

Three previous immunizations?

Infection of the finger pad (Think: Felon Finger printing)

Sulfur granules

Clostridium tetani

Lockjaw, muscle spasm, laryngospasm, convulsions, respiratory failure

None (tetanus toxoid only if 5 years since last toxoid)

180 Section I / Overview and Background Surgical Information

Two previous	Tetanus toxoid
immunizations?
One previous	Tetanus immunoglobulin IM and tetanus
immunization?	toxoid IM (at different sites!)
No previous	Tetanus immunoglobulin IM and tetanus
immunizations?	toxoid IM (at different sites!)
What is Fitz-Hugh-Curtis	Right upper quadrant pain from
syndrome?	gonococcal perihepatitis in women

C h a p t e r 28

Define postoperative fever.

What are the classic W’s of postoperative fever? (5)

Give the classic postoperative timing for the following causes of postoperative fever:

Atelectasis (Wind)

UTI (Water)

Wound infection (Wound)

DVT/PE/thrombophlebitis

(Walking)

Drug fever (Wonder drugs)

What is the most common cause of fever on postoperative days 1 to 2?

Fever

Temperature 38.5 C or 101.5 F

Wind—atelectasis

Water—urinary tract infection (UTI) Wound—wound infection Walking—DVT/thrombophlebitis Wonder drugs—drug fever

First 24 to 48 hours

Anytime after POD #3

Usually after POD #5 (but it can be anytime!)

PODs #7 to #10

Anytime

Atelectasis

What is a “complete” fever workup?

What causes fever before 24 postoperative hours?

What causes fever from postoperative days 3 to 5?

What is an anesthetic cause of fever INTRAoperatively?

What causes fever from postoperative days 5 to 10?

What causes wound infection on postoperative days 1 to 2?

What can cause fever at any time?

Chapter 29 / Surgical Prophylaxis 181

Physical exam (look at wound, etc.), CXR, urinalysis, blood cultures, CBC

Atelectasis, -hemolytic streptococcal or clostridial wound infections, anastomotic leak

UTI, pneumonia, IV site infection, wound infection

Malignant hyperthermia—treat with dantrolene

Wound infection, pneumonia, abscess, infected hematoma, C. difficile colitis, anastomotic leak

DVT, peritoneal abscess, drug fever

Pulmonary embolism, abscess, parotitis

Streptococcus

Clostridia (painful bronze-brown weeping wound)

1.IV site infection

2.Central line infection

3.Medications

C h a p t e r 29

Surgical

Prophylaxis

What medications provide	H2 blockers, PPI (proton-pump inhibitor)
protection from postoperative
GI bleeding?
What measures provide	Incentive spirometry, coughing, smoking
protection from postoperative	cessation, ambulation
atelectasis/pneumonia?
What treatments provide	Low-molecular-weight heparin (LMWH),
protection from postoperative	subcutaneous low-dose unfractionated
DVT?	heparin, sequential compression device
	(SCD) for lower extremities, or both;
	early ambulation

182 Section I / Overview and Background Surgical Information

What measures provide	Shower the night before surgery with
protection from wound	chlorhexidine scrub
infection?	Never use a razor for hair removal
	(electric shavers only)
	Ensure adequate skin prep in O.R.
	Do not close the skin in a contaminated case
	Ensure preoperative antibiotics in the
	bloodstream before incision
	Ensure no excess Bovie (necrotic tissue)

Why not use a razor to remove hair?

How long should “prophylactic antibiotics” be given?

What treatment provides protection from oral/esophageal fungal infection during IV antibiotic treatment?

Micro cuts are a nidus for bacteria and subsequent wound infection

24 hrs

PO nystatin

What measures prevent	Head of bed 30 , handwashing, patient
ventilator-associated	oral hygiene, avoidance of gastric
pneumonia (VAP)?	overdistention
What is the classic	1.	Bowel prep: Lower bacterial count in
preoperative “bowel prep”?		colon by catharsis (GoLYTELY or
		Fleets)
	2.	PO antibiotics (neomycin, erythromycin)
		preoperatively
	3.	Preoperative IV antibiotic with spectrum
		versus anaerobes (e.g., Cefoxitin)
Is there any evidence that a	NO
“bowel prep” decreases
infections?

What treatment provides protection from OPSS after splenectomy?

What treatment provides protection from endocarditis with faulty heart valve or prosthetic heart valve?

Immunization against H. influenzae, Streptococcus, Meningococcus, and penicillin when illness/fever occurs

Antibiotics prior to dental procedure or any surgery