Surgical Infection, C27 P170-180 Flashcards
1
Q
What are the classic signs/ symptoms of inflammation/ infection?
P170
A
Tumor (mass = swelling/edema)
Calor (heat)
Dolor (pain)
Rubor (redness = erythema)
2
Q
Define:
Bacteremia
P170
A
Bacteria in the blood
3
Q
Define:
SIRS
P170
A
Systemic Inflammatory Response Syndrome (fever, tachycardia, tachypnea, leukocytosis)
4
Q
Define:
Sepsis
P170
A
Documented infection and SIRS
5
Q
Define:
Septic shock
P170
A
Sepsis and hypotension
6
Q
Define:
Cellulitis
P170
A
Blanching erythema from superficial
dermal/epidermal infection (usually strep
more than staph)
7
Q
Define:
Abscess
P170
A
Collection of pus within a cavity
8
Q
Define:
Superinfection
P170
A
New infection arising while a patient is
receiving antibiotics for the original infection at a different site (e.g., C. difficile colitis)
9
Q
Define:
Nosocomial infection
P170
A
Infection originating in the hospital
10
Q
Define:
Empiric
P170
A
Use of antibiotic based on previous sensitivity information or previous experience awaiting culture results in an established infection
11
Q
Define:
Prophylactic
P170
A
Antibiotics used to prevent an infection
12
Q
What is the most common nosocomial infection?
P170
A
Urinary tract infection (UTI)
13
Q
What is the most common nosocomial infection causing death?
P170
A
Respiratory tract infection (pneumonia)
14
Q
URINARY TRACT INFECTION (UTI)
What diagnostic tests are used?
P171
A
Urinalysis, culture, urine microscopy for WBC
15
Q
URINARY TRACT INFECTION (UTI)
What constitutes a POSITIVE urine analysis?
P171
A
Positive nitrite (from bacteria)
Positive leukocyte esterase (from WBC)
>10 WBC/HPF
Presence of bacteria (supportive)
16
Q
URINARY TRACT INFECTION (UTI)
What number of colonyforming units (CFU)
confirms the diagnosis of UTI?
P171
A
On urine culture, classically 100,000 or
105 CFU
17
Q
URINARY TRACT INFECTION (UTI)
What are the common organisms?
P171
A
Escherichia coli, Klebsiella, Proteus
Enterococcus, Staphylococcus aureus
18
Q
URINARY TRACT INFECTION (UTI)
What is the treatment?
P171
A
Antibiotics with gram-negative spectrum
(e.g., sulfamethoxazole/trimethoprim
[Bactrim™], gentamicin, ciprofloxacin,
aztreonam); check culture and sensitivity
19
Q
URINARY TRACT INFECTION (UTI)
What is the treatment of bladder candidiasis?
P171
A
- Remove or change Foley catheter
- Administer systemic fluconazole or
amphotericin bladder washings
20
Q
CENTRAL LINE INFECTIONS
What are the signs of a central line infection?
P171
A
Unexplained hyperglycemia, fever,
mental status change, hypotension,
tachycardia → shock, pus, and erythema
at central line site
21
Q
CENTRAL LINE INFECTIONS
What is the most common cause of “catheter-related bloodstream infections”?
P171
A
Coagulase-negative staphylococcus (33%),
followed by enterococci, Staphylococcus
aureus, gram-negative rods
22
Q
CENTRAL LINE INFECTIONS
When should central lines be changed?
P171
A
When they are infected; there is NO
advantage to changing them every 7 days
in nonburn patients
23
Q
CENTRAL LINE INFECTIONS
What central line infusion increases the risk of
infection?
P171
A
Hyperal (TPN)
24
Q
CENTRAL LINE INFECTIONS
What is the treatment for central line infection?
P172
A
- Remove central line (send for culture)
+/- IV antibiotics - Place NEW central line in a different site
25
CENTRAL LINE INFECTIONS
When should peripheral IV short angiocatheters be changed?
P172
Every 72 to 96 hours
26
WOUND INFECTION (SURGICAL SITE INFECTION)
What is it?
P172
Infection in an operative wound
27
```
WOUND INFECTION (SURGICAL SITE INFECTION)
When do these infections arise?
P172
```
Classically, PODs #5 to #7
28
WOUND INFECTION (SURGICAL SITE INFECTION)
What are the signs/symptoms?
P172
Pain at incision site, erythema, drainage,
| induration, warm skin, fever
29
WOUND INFECTION (SURGICAL SITE INFECTION)
What is the treatment?
P172
Remove skin sutures/staples, rule out
fascial dehiscence, pack wound open, send
wound culture, administer antibiotics
30
WOUND INFECTION (SURGICAL SITE INFECTION)
What are the most common bacteria found in postoperative wound infections?
P172
```
Staphylococcus aureus (20%)
Escherichia coli (10%)
Enterococcus (10%)
Other causes:
Staphylococcus epidermidis,
Pseudomonas, anaerobes, other
gram-negative organisms,
Streptococcus
```
31
WOUND INFECTION (SURGICAL SITE INFECTION)
Which bacteria cause fever and wound infection in the first 24 hours after surgery?
P172
1. Streptococcus
2. Clostridium
(bronze-brown weeping tender wound)
32
CLASSIFICATION OF OPERATIVE WOUNDS
What is a “clean” wound?
P172
Elective, nontraumatic wound without acute inflammation; usually closed primarily without the use of drains
33
CLASSIFICATION OF OPERATIVE WOUNDS
What is the infection rate of a clean wound?
P172
1.5%
34
CLASSIFICATION OF OPERATIVE WOUNDS
What is a clean-contaminated wound?
P173
Operation on the GI or respiratory tract
without unusual contamination or entry
into the biliary or urinary tract
35
CLASSIFICATION OF OPERATIVE WOUNDS
Without infection present, what is the infection rate of a clean-contaminated wound?
P173
36
CLASSIFICATION OF OPERATIVE WOUNDS
What is a contaminated wound?
P173
Acute inflammation, traumatic wound,
| GI tract spillage, or a major break in sterile technique
37
CLASSIFICATION OF OPERATIVE WOUNDS
What is the infection rate of a contaminated wound?
P173
≈5%
38
CLASSIFICATION OF OPERATIVE WOUNDS
What is a dirty wound?
P173
Pus present, perforated viscus, or dirty
| traumatic wound
39
CLASSIFICATION OF OPERATIVE WOUNDS
What is the infection rate of a dirty wound?
P173
≈33%
40
CLASSIFICATION OF OPERATIVE WOUNDS
What are the possible complications of wound
infections?
P173
Fistula, sinus tracts, sepsis, abscess,
suppressed wound healing, superinfection
(i.e., a new infection that develops during
antibiotic treatment for the original infection), hernia
41
CLASSIFICATION OF OPERATIVE WOUNDS
What factors influence the development of infections?
P173
- Foreign body (e.g., suture, drains, grafts)
- Decreased blood flow (poor delivery of PMNs
and antibiotics)
- Strangulation of tissues with excessively tight
sutures
- Necrotic tissue or excessive local tissue
destruction (e.g., too much Bovie)
- Long operations (2 hrs)
- Hypothermia in O.R.
- Hematomas or seromas
- Dead space that prevents the delivery of
phagocytic cells to bacterial foci
- Poor approximation of tissues
42
CLASSIFICATION OF OPERATIVE WOUNDS
What patient factors influence the development
of infections?
P173
```
Uremia
Hypovolemic shock
Vascular occlusive states
Advanced age
Distant area of infection
```
43
CLASSIFICATION OF OPERATIVE WOUNDS
What are examples of an immunosuppressed state?
P174
```
Immunosuppressant treatment
Chemotherapy
Systemic malignancy
Trauma or burn injury
Diabetes mellitus
Obesity
Malnutrition
AIDS
Uremia
```
44
CLASSIFICATION OF OPERATIVE WOUNDS
Which lab tests are indicated?
P174
CBC: leukocytosis or leukopenia (as an abscess may act as a WBC sink), blood cultures, imaging studies (e.g., CT scan to locate an abscess)
45
CLASSIFICATION OF OPERATIVE WOUNDS
What is the treatment?
P174
Incision and drainage—an abscess must be
drained (Note: fluctuation is a sign of a
subcutaneous abscess; most abdominal
abscesses are drained percutaneously)
Antibiotics for deep abscesses
46
CLASSIFICATION OF OPERATIVE WOUNDS
What are the indications for antibiotics after drainage of a subcutaneous abscess?
P174
Diabetes mellitus, surrounding cellulitis,
| prosthetic heart valve, or an immunocompromised state
47
PERITONEAL ABSCESS
What is a peritoneal abscess?
P174
Abscess within the peritoneal cavity
48
PERITONEAL ABSCESS
What are the causes?
P174
Postoperative status after a laparotomy,
ruptured appendix, peritonitis, any
inflammatory intraperitoneal process,
anastomotic leak
49
PERITONEAL ABSCESS
What are the sites of occurrence?
P174
Pelvis, Morison’s pouch, subphrenic,
| paracolic gutters, periappendiceal, lesser sac
50
PERITONEAL ABSCESS
What are the signs/symptoms?
P174
Fever (classically spiking), abdominal pain, mass
51
PERITONEAL ABSCESS
How is the diagnosis made?
P174
Abdominal CT scan (or ultrasound)
52
PERITONEAL ABSCESS
When should an abdominal CT scan be obtained looking for a postoperative abscess?
P175
After POD #7 (otherwise, abscess will not be “organized” and will look like a normal postoperative fluid collection)
53
PERITONEAL ABSCESS
What CT scan findings are
associated with abscess?
P175
Fluid collection with fibrous rind, gas in
| fluid collection
54
PERITONEAL ABSCESS
What is the treatment?
P175
Percutaneous CT–guided drainage
55
PERITONEAL ABSCESS
What is an option for
drainage of pelvic abscess?
P175
Transrectal drainage (or transvaginal)
56
PERITONEAL ABSCESS
All abscesses must be
drained except which type?
P175
Amebiasis!
57
NECROTIZING FASCIITIS
What is it?
P175
Bacterial infection of underlying fascia
| spreads rapidly along fascial planes
58
NECROTIZING FASCIITIS
What are the causative agents?
P175
Classically, group A Streptococcus
pyogenes, but most often polymicrobial
with anaerobes/gram-negative organisms
59
NECROTIZING FASCIITIS
What are the signs/symptoms?
P175
```
Fever, pain, crepitus, cellulitis, skin
discoloration, blood blisters (hemorrhagic
bullae), weeping skin, increased
WBCs, subcutaneous air on x-ray, septic
shock
```
60
NECROTIZING FASCIITIS
What is the treatment?
P175
IVF, IV antibiotics and aggressive early
extensive surgical débridement, cultures,
tetanus prophylaxis
61
NECROTIZING FASCIITIS
Is necrotizing fasciitis an
emergency?
P175
YES, patients must be taken to the O.R.
| immediately!
62
CLOSTRIDIAL MYOSITIS
What is it?
P175
Clostridial muscle infection
63
CLOSTRIDIAL MYOSITIS
What is another name for
this condition?
P175
Gas gangrene
64
CLOSTRIDIAL MYOSITIS
What is the most common
causative organism?
P176
Clostridium perfringens
65
CLOSTRIDIAL MYOSITIS
What are the signs/symptoms?
P176
Pain, fever, shock, crepitus, foul-smelling
| brown fluid, subcutaneous air on x-ray
66
CLOSTRIDIAL MYOSITIS
What is the treatment?
P176
IV antibiotics, aggressive surgical
débridement of involved muscle, tetanus
prophylaxis
67
SUPPURATIVE HIDRADENITIS
What is it?
P176
Infection/abscess formation in apocrine
| sweat glands
68
SUPPURATIVE HIDRADENITIS
In what three locations does
it occur?
P176
Perineum/buttocks, inguinal area, axillae
| site of apocrine glands
69
SUPPURATIVE HIDRADENITIS
What is the most common
causative organism?
P176
Staphylococcus aureus
70
SUPPURATIVE HIDRADENITIS
What is the treatment?
P176
Antibiotics
Incision and drainage (excision of skin
with glands for chronic infections)
71
PSEUDOMEMBRANOUS COLITIS
What is it?
P176
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)
72
PSEUDOMEMBRANOUS COLITIS
What are the signs/symptoms?
P176
Diarrhea (bloody in 10% of patients),
± fever, ± increased WBCs, ± abdominal
cramps, ± abdominal distention
73
PSEUDOMEMBRANOUS COLITIS
What causes the diarrhea?
P176
Exotoxin released by C. difficile
74
PSEUDOMEMBRANOUS COLITIS
How is the diagnosis made?
P176
```
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”)
```
75
PSEUDOMEMBRANOUS COLITIS
What is the treatment?
P177
PO metronidazole (Flagyl®; 93% sensitive)
or PO vancomycin (97% sensitive);
discontinuation of causative agent
Never give antiperistaltics
76
PROPHYLACTIC ANTIBIOTICS
What are the indications for
prophylactic IV antibiotics?
P177
```
Accidental wounds with heavy
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
```
77
```
PROPHYLACTIC ANTIBIOTICS
What must a prophylactic
antibiotic cover for
procedures on the large
bowel/abdominal
trauma/appendicitis?
P177
```
Anaerobes
78
```
PROPHYLACTIC ANTIBIOTICS
What commonly used
antibiotics offer anaerobic
coverage?
P177
```
Cefoxitin (Mefoxin®), clindamycin,
metronidazole (Flagyl®), cefotetan,
ampicillin-sulbactam (Unasyn®), Zosyn™,
Timentin®, Imipenem®
79
```
PROPHYLACTIC ANTIBIOTICS
What antibiotic is used
prophylactically for vascular
surgery?
P177
```
Ancef (if patient is significantly allergic
to PCN—hives/swelling/shortness of
breath—then erythromycin or
clindamycin are options)
80
```
PROPHYLACTIC ANTIBIOTICS
When is the appropriate
time to administer
prophylactic antibiotics?
P177
```
Must be in adequate levels in the blood
| stream prior to surgical incision!
81
PAROTITIS
What is it?
P178
Infection of the parotid gland
82
PAROTITIS
What is the most common
causative organism?
P178
Staphylococcus
83
PAROTITIS
What are the associated risk
factors?
P178
Age older than 65 years, malnutrition,
poor oral hygiene, presence of NG tube,
NPO, dehydration
84
PAROTITIS
What is the most common
time of occurrence?
P178
Usually 2 weeks postoperative
85
PAROTITIS
What are the signs?
P178
Hot, red, tender parotid gland and
| increased WBCs
86
PAROTITIS
What is the treatment?
P178
Antibiotics, operative drainage as
| necessary
87
MISCELLANEOUS
What is a “stitch” abscess?
P178
Subcutaneous abscess centered around a
subcutaneous stitch, which is a “foreign
body”; treat with drainage and stitch
removal
88
MISCELLANEOUS
Which bacteria can be found
in the stool (colon)?
P178
Anaerobic—Bacteroides fragilis
| Aerobic—Escherichia coli
89
MISCELLANEOUS
Which bacteria are found in
infections from human bites?
P178
Streptococcus viridans, S. aureus,
Peptococcus, Eikenella (treat with
Augmentin®)
90
MISCELLANEOUS
What are the most common
ICU pneumonia bacteria?
P178
Gram-negative organisms
91
MISCELLANEOUS
What is Fournier’s
gangrene?
P178
Perineal infection starting classically in
the scrotum in patients with diabetes;
treat with triple antibiotics and wide
débridement—a surgical emergency!
92
```
MISCELLANEOUS
Does adding antibiotics to
peritoneal lavage solution
lower the risk of abscess
formation?
P178
```
No (“Dilution is the solution to
| pollution”)
93
```
MISCELLANEOUS
What is the classic
finding associated with a
Pseudomonas infection?
P179
```
Green exudate and “fruity” smell
94
```
MISCELLANEOUS
What are the classic
antibiotics for “triple”
antibiotics?
P179
```
Ampicillin, gentamycin, and
| metronidazole (Flagyl®)
95
MISCELLANEOUS
Which antibiotic is used to
treat amoeba infection?
P179
Metronidazole (Flagyl®)
96
```
MISCELLANEOUS
Which bacteria commonly
infect prosthetic material
and central lines?
P179
```
Staphylococcus epidermis
97
MISCELLANEOUS
What is the antibiotic of
choice for Actinomyces?
P179
Penicillin G (exquisitely sensitive)
98
MISCELLANEOUS
What is a furuncle?
P179
```
Staphylococcal abscess that forms in a
hair follicle (Think: Follicle = Furuncle)
```
99
MISCELLANEOUS
What is a carbuncle?
P179
Subcutaneous staphylococcal abscess
(usually an extension of a furuncle), most
commonly seen in patients with diabetes
(i.e., rule out diabetes)
100
MISCELLANEOUS
What is a felon?
P179
Infection of the finger pad
| Think: Felon = Finger printing
101
MISCELLANEOUS
What microscopic finding is
associated with Actinomyces?
P179
Sulfur granules
102
MISCELLANEOUS
What organism causes
tetanus?
P179
Clostridium tetani
103
MISCELLANEOUS
What are the signs of
tetanus?
P179
Lockjaw, muscle spasm, laryngospasm,
| convulsions, respiratory failure
104
```
MISCELLANEOUS
What are the appropriate
prophylactic steps in
tetanus-prone (dirty) injury
in the following patients:
```
Three previous
immunizations?
P179
None (tetanus toxoid only if >5 years
| since last toxoid)
105
```
MISCELLANEOUS
What are the appropriate
prophylactic steps in
tetanus-prone (dirty) injury
in the following patients:
```
Two previous
immunizations?
P180
Tetanus toxoid
106
```
MISCELLANEOUS
What are the appropriate
prophylactic steps in
tetanus-prone (dirty) injury
in the following patients:
```
One previous
immunization?
P180
```
Tetanus immunoglobulin IM and tetanus
toxoid IM (at different sites!)
```
107
```
MISCELLANEOUS
What are the appropriate
prophylactic steps in
tetanus-prone (dirty) injury
in the following patients:
```
No previous
immunizations?
P180
```
Tetanus immunoglobulin IM and tetanus
toxoid IM (at different sites!)
```
108
MISCELLANEOUS
What is Fitz-Hugh-Curtis
syndrome?
P180
Right upper quadrant pain from
| gonococcal perihepatitis in women
