Microbiology for Surgical Infections. Diagnosis, Prognosis and Treatment

293 Pages·2014·9.817 MB·English

by  Kateryna Kon and Mahendra Rai (Auth.)

MICROBIOLOGY FOR SURGICAL
INFECTIONS
MICROBIOLOGY
FOR SURGICAL
INFECTIONS
DIAGNOSIS, PROGNOSIS AND
TREATMENT
Edited by
Kateryna Kon MD, PhD
KharkivNationalMedicalUniversity,Kharkiv,Ukraine
Mahendra Rai MSc, PhD
SantGadgeBabaAmravatiUniversity,Amravati,Maharashtra,India
DepartmentofChemicalBiology,InstituteofChemistry,UniversityofCampinas,CampinasSP,Brazil
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Preface
Surgical infections represent a diverse group of diseases, which despite advances in
techniques of surgery and anesthesia, the presence of modern equipment and improving
perioperative health care in hospitals, still lead to significant morbidity and mortality. The
rapid increase in levels of antibiotic resistance and the appearance of new multidrug-
resistant pathogensmakes it necessary toconstantly updaterecommendations onthe man-
agement of infections, and the present book reviews the most recent guidelines on the
prevention, diagnosis and treatment of surgical infections of different locations, with par-
ticular emphasis on intra-abdominal, cardiovascularand skin andsofttissue infections.
The scope of the chapters encompasses reviews of in vitro studies of the principles of
prevention of surgical infections, such as the evaluation of bacterial adherence to surgical
materials, as well as clinical studies on the management of a broad spectrum of surgical
infections, including anastomotic leakage after colorectal surgery, infectious complications
of dialysis access, infective endocarditis, necrotizing soft tissue infections, diabetic foot
infections and others. In addition, alternative methods of antimicrobial treatment of surgi-
cal infections are also discussed in several chapters, such as in vitro and in vivo studies on
wound healing and anti-infectious properties of plant extracts, essential oils, and zoothera-
peutics methods.
Although the most common cause of surgical infections is bacteria, the role of other
microorganisms should not be disregarded. In consideration of this fact, one chapter is
also devoted to understanding diagnostic approaches for invasive mycoses in surgical
patients,as this pathologyhas attracted much attention in recent years.
Selection of the optimal treatment strategy is impossible without predicting a probable
outcomeoftheinfectionbasedonapatient’slaboratoryandclinicalparameters.Nowadays,
there are a large number of studies dedicated to the development of scoring systems using
modern statistical methods for assessment of the severity of a patient’s state and for pre-
dicting the course and outcome in different surgical infections. Some such scoring systems
have gained great popularity in the medical community, such as APACHE II (Acute
Physiology and Chronic Health Evaluation II) system, SAPS (Simplified Acute Physiology
Score),MPI(MannheimPeritonitisIndex),etc.,andthisbookalsosummarizesstudiesofthe
efficacy of these and other scoring systems in the prognosis of surgical infections, particu-
larlyinsecondaryperitonitis.
The book explores current trends in the etiology and antibiotic resistance of pathogens
causing different types of surgical infections; it discusses recent advances in diagnostic
approaches in bacterial and non-bacterial surgical infections; it reviews methods of prog-
nosis of the course and outcome of surgical infections; and it also summarizes recent
ix
x
PREFACE
guidelines for prophylaxis of infectious complications in surgery, and for improvement of
diagnosis andtreatment of surgical infections.
The book will beveryuseful to microbiologists,surgeons, infectiousdiseasesspecialists,
researchers in surgery, clinical microbiologists, pharmacologists, and those who are inter-
ested in tacklingthe problem of antibioticresistance.
The editors would like to thank Elizabeth Gibson, Editorial Project Manager, Academic
Press/Elsevier S&T Books, Waltham, MA, USA for her help and valuable suggestions, the
contributors for devoting their time and efforts to this book, and the reviewers for their
comments for improving the chapters. Prof. Rai thankfully acknowledges FAPESP, Brazil
for providing financial support to visit the Institute of Chemistry, Biological Chemistry
Laboratory, Universidade Estadual de Campinas, Campinas, SP, Brazil.
Kateryna Kon
Mahendra Rai
List of Contributors
Ali Alizzi Cardiothoracic Surgical Unit, Elena Eraso Departamento de Inmunolog´ıa,
AshfordHospital,Adelaide,Australia. Microbiolog´ıa y Parasitolog´ıa, Universidad
Luca Ansaloni General Surgery Department, del Pa´ıs Vasco/Euskal Herriko Unibertsitatea
(UPV/EHU),Bilbao,Spain.
PapaGiovanniXXIIIHospital,Bergamo,Italy.
VenkateshKumarAriyamuthu Departmentof Jaime Esteban Department of Clinical
Medicine, University of Missouri Columbia, Microbiology, IIS-Fundacio´n Jime´nez D´ıaz,
Missouri. Madrid,Spain.
Ramkrishna Bhalchandra Tata Medical Leticia M. Estevinho CIMO-Mountain
Center,Kolkata,India. Research Center, Department of Biology and
Biotechnology, Agricultural College of
Sanjay Bhattacharya Tata Medical Center,
Braganc¸a, Polytechnic Institute of Braganc¸a,
Kolkata,India.
Braganc¸a,Portugal.
Rodolfo Leonel Bracho-Riquelme Instituto de
Guillermo Ezpeleta Departamento de
Investigacio´n Cient´ıfica de la Universidad
Medicina Preventiva y Salud Pu´blica,
Jua´rez del Estado de Durango, Durango,
Facultad de Medicina y Odontolog´ıa,
Me´xico.
Universidad del Pa´ıs Vasco/Euskal
Michela Giulii Capponi General Surgery
Herriko Unibertsitatea (UPV/EHU), Bilbao,
Department, Papa Giovanni XXIII Hospital, Spain.
Bergamo,Italy.
Xesus Fea´s Department of Organic Chemistry,
Kunal Chaudhary Department of Medicine,
Faculty ofSciences, University ofSantiago de
UniversityofMissouriColumbia,Missouri.
Compostela,Lugo,Spain.
Yi-Feng Chen Institute of Biotechnology, Donald E. Fry Department of Surgery,
Jiangsu Academy of Agricultural Sciences, Northwestern University Feinberg School of
Nanjing,Jiangsu,China.
Medicine, Chicago, Illinois, and the
Andreas K. Demetriades Department of Department of Surgery, University of New
Neurosurgery, Western General Hospital, Mexico School of Medicine, Albuquerque,
Edinburgh,UK. NewMexico.
Daliparthy Devi Pratyush Department of Vikas Gautam Department of Medical
Endocrinology and Metabolism, Institute of Microbiology, Postgraduate Institute of
Medical Sciences, Banaras Hindu University, Medical Education and Research,
Varanasi,India. Chandigarh,India.
Lu´ısG.Dias CIMO-MountainResearchCenter, Gaurav Goel Tata Medical Center, Kolkata,
Department of Biology and Biotechnology, India.
Agricultural College of Braganc¸a, Polytechnic Enrique Go´mez-Barrena Department of
InstituteofBraganc¸a,Braganc¸a,Portugal. Orthopedics, IdiPAZ-Hospital Universitario
Teresa Dias CIMO-Mountain Research Center, LaPaz,Madrid,Spain.
Department of Biology and Biotechnology, KarolinGraf InstituteforMedicalMicrobiology
Agricultural College of Braganc¸a, Polytechnic and Hospital Epidemiology, Hannover
InstituteofBraganc¸a,Braganc¸a,Portugal. MedicalSchool,Hannover,Germany.
xi
xii
LISTOFCONTRIBUTORS
Sanjeev Kumar Gupta Department of General Guillermo Quindo´s Departamento de
Surgery, Institute of Medical Sciences, Inmunolog´ıa, Microbiolog´ıa y Parasitolog´ıa,
BanarasHinduUniversity,Varanasi,India. Universidad del Pa´ıs Vasco/Euskal
TorstenHerzog DepartmentofSurgery,St.Josef Herriko Unibertsitatea (UPV/EHU), Bilbao,
Spain.
Hospital,Ruhr-UniversityBochum,Germany.
Lalawmpuia Hmar Tata Medical Center, Mahendra Rai Department of Biotechnology,
Kolkata,India. Sant Gadge Baba Amravati University,
Amravati,Maharashtra,India.
Kateryna Kon Department of Microbiology,
Hariharan Regunath Department of Medicine,
Virology and Immunology, Kharkiv National
UniversityofMissouriColumbia,Missouri.
MedicalUniversity,Kharkiv,Ukraine.
Surya Kumar Singh Department of Florian Ringel Department of Neurosurgery,
Endocrinology and Metabolism, Institute of Klinikum rechts der Isar, Technische
Medical Sciences, Banaras Hindu University, Universita¨tMu¨nchen,Mu¨nchen,Germany.
Varanasi,India. FerranSanchez-Reus ServiciodeMicrobiolog´ıa,
Ali Parsaeimehr G. S. Davtyan Institute of HospitaldelaSantaCreuiSantPau,Barcelona,
HydroponicsProblems,NationalAcademyof Spain.
Sciences,Yerevan,RepublicofArmenia. Elmira Sargsyan G. S. Davtyan Institute of
Ananias Pascoal CIMO-Mountain Research HydroponicsProblems,NationalAcademyof
Sciences,Yerevan,RepublicofArmenia.
Center, Department of Biology and
Biotechnology, Agricultural College of Sarah Shepard SA Pathology, Adelaide,
Braganc¸a, Polytechnic Institute of Braganc¸a, Australia.
Braganc¸a,Portugal. Lipika Singhal Department of Medical
Javier Pema´n Servicio de Microbiolog´ıa, Microbiology,PostgraduateInstituteofMedical
HospitalUniversitarioLaFe,Valencia,Spain. EducationandResearch,Chandigarh,India.
Concepcio´n Pe´rez-orge-eremarch Department John-Paul Tantiongco Cardiothoracic Surgical
ofClinicalMicrobiology,IIS-Fundacio´nJime´nez Unit, Flinders Medical Center, Adelaide,
D´ıaz,Madrid,Spain. Australia.
Ramo´n Pe´rez-Tanoira Department of Clinical Shalbha Tiwari Department of Endocrinology
Microbiology, IIS-Fundacio´n Jime´nez D´ıaz, and Metabolism, Institute of Medical
Madrid,Spain. Sciences, Banaras Hindu University,
Michele Pisano General Surgery Department, Varanasi,India.
PapaGiovanniXXIIIHospital,Bergamo,Italy. Waldemar Uhl Department of Surgery, St.
Elia Poiasina General Surgery Department, Josef Hospital, Ruhr-University Bochum,
PapaGiovanniXXIIIHospital,Bergamo,Italy. Germany.
Amber Prasad Department of Medical Ralf-Peter Vonberg Institute for Medical
Microbiology,PostgraduateInstituteofMedical Microbiology and Hospital Epidemiology,
EducationandResearch,Chandigarh,India. HannoverMedicalSchool,Hannover,Germany.
C H A P T E R
1
Infection Control Measures for the
Prevention of Surgical Site Infections
Karolin Graf and Ralf-Peter Vonberg
Institutefor Medical Microbiology and Hospital Epidemiology,
Hannover Medical School,Hannover,Germany
CONSEQUENCES OF SURGICAL SITE INFECTIONS
It is as simple as this: The best you can do about surgical site infections (SSI) is not to
let them happen in the first place. Today the occurrence of SSI represents one of the most
severe complications in all types of surgical procedures, and it will have an enormous
impact on the ongoing course of recovery of the affected patient. It leads to significantly
increased morbidity and mortality of patients in various medical disciplines.1(cid:1)3 Besides
their importance with respectto suchclinicalconsequences,SSI should also concern hospi-
tals and health care systems for economic reasons.4,5 Depending upon the type of surgery,
the prolonged length of stay (LOS) in the hospital may vary from 3 to 21 days.1 According
to a review of the literature on SSI in general6 and to a recently published large estimation
onSSIinorthopedics(412,356totalhipand784,335totalkneearthroplasties)inparticular,7
SSI will roughly double the magnitude of the cost for a case patient. Based on the 2005
Healthcare Cost and Utilization Project National Inpatient Sample (HCUP NIS), which
included 723,490 surgical patients with 6,891 SSI, the average LOS was 9.7 days and costs
increased by $20,842 per admission. This leads to nearly 1,000,000 additional inpatient-
days and $1,600,000,000 excess costs for the US alone.8
Evidence-based infection control guidelines for the prevention of SSI have been pub-
lished, for example by the Hospital Infection Control Practices Advisory Committee
(HICPAC) from the Centers for Disease Control and Prevention (CDC)9 and by the Society
for Healthcare Epidemiology of America (SHEA) in collaboration with the Infectious
Diseases Society of America (IDSA) (Table 1.1).10 This chapter provides an overview of
patient-derived (endogenous) risk factors for SSI development, and summarizes the most
MicrobiologyforSurgicalInfections
DOI:http://dx.doi.org/10.1016/B978-0-12-411629-0.00001-5 3 ©2014ElsevierInc.Allrightsreserved.
4
1. INFECTIONCONTROLMEASURESFORTHEPREVENTIONOFSURGICALSITEINFECTIONS
TABLE1.1 SummaryofEvidence-basedRecommendationsoftheSocietyforHealthcareEpidemiologyof
America(SHEA)forSSIPrevention
Recommendation Grade
Useevidence-basedstandardswhenimplementingpreventionmeasures. A-II
Controlserumbloodglucoselevels;reduceglycosylatedhemoglobinA1clevelsto,7%beforesurgery, A-II
ifpossible.
Increasedosingofprophylacticantimicrobialagentformorbidlyobesepatients. A-II
Encouragesmokingcessationwithin30daysbeforeprocedure. A-II
Noformalrecommendationwithrespecttoimmunosuppressivemedications;avoidtheminthe C-II
perioperativeperiod,ifpossible.
Donotroutinelydelaysurgerytoprovideparenteralnutrition. A-I
Donotremoveunlesshairwillinterferewiththeoperation;ifremovalisnecessary,removeby A-II
clippinganddonotuserazors.
Identifyandtreatinfectionsremotetothesurgicalsitebeforeelectivesurgery. A-II
Washandcleanskinaroundincisionsite;useanappropriateantisepticagent. A-II
Useappropriateantisepticagent(e.g.,analcohol-basedsurgicalhandantisepsisproduct)fora A-II
2(cid:1)5minutepreoperativesurgicalscrub.
Administerantimicrobialprophylaxisonlywhenindicatedinaccordancewithevidence-based A-I
standardsandguidelines.
Administerantimicrobialprophylaxiswithin1hourbeforeincisiontomaximizetissueconcentration. A-I
Selectappropriateagentsonthebasisofsurgicalprocedure,mostcommonpathogens,andpublished A-I
recommendations.
Donotroutinelyusevancomycinforantimicrobialprophylaxis. B-II
Stopprophylaxiswithin24hoursaftertheprocedureforallproceduresexceptcardiacsurgery A-I
(stopwithin48hourshere).
Handletissuecarefullyanderadicatedeadspace. A-III
Controlbloodglucoselevelduringtheimmediatepostoperativeperiodforpatientsundergoing A-I
cardiacsurgery.
Adheretostandardprinciplesofoperatingroomasepsis. A-III
Noformalrecommendationwithrespecttooperativetime;minimizeasmuchaspossible. A-III
Adheretoventilation,followAmericanInstituteofArchitects’recommendationsforventilation. C-I
Minimizeoperatingroomtraffic. B-II
Useanapprovedhospitaldisinfectanttocleansurfacesandequipment. B-III
Sterilizeallsurgicalequipmentaccordingtopublishedguidelines;minimizetheuseofflash B-I
sterilization.
PerformsurveillanceforSSI. A-II
(Continued)
I. INFECTIONCONTROLMEASURESFORTHEPREVENTIONOFSURGICALINFECTIONS
5
INFECTIONCONTROLMEASURESBEFORETHESTARTOFTHESURGICALPROCEDURE
TABLE1.1 (Continued)
Recommendation Grade
ProvideongoingfeedbackonSSIsurveillanceandprocessmeasurestosurgicalandperioperative A-II
personnelandleadership.
PerformexpandedSSIsurveillancetodeterminethesourceandextentoftheproblemandtoidentify B-II
possibletargetsforintervention.
MeasureandprovidefeedbackofSSIrates,antimicrobialprophylaxis,properhairremoval,and A-III
glucosecontrol(forcardiacsurgery)
Increasetheefficiencyofsurveillancethroughtheuseofautomateddata. A-II
EducatesurgeonsandperioperativepersonnelaboutSSIprevention. A-III
EducatepatientsandtheirfamiliesaboutSSIprevention,asappropriate. A-III
important infection control measures according to the time point of their implementation
(before, duringor after the operation on thepatient).
INFECTION CONTROL MEASURES BEFORE THE START
OF THE SURGICAL PROCEDURE
Patient-Derived (Endogenous) Risk Factors for Surgical Site Infections
Diseases. Some patients present with certain characteristics that will increase their risk of
subsequent SSI acquisition. Unfortunately, a number of those endogenous risk facts cannot
be influenced by proper infection control measures. This includes (but does not exclusively
applyto)underlyingdiseaseswhichincreasetheoverallcomorbiditiyburdensuchascancer,
cirrhosis and other liver diseases, congestive heart failure, coagulopathies, and chronic
obstructive lung diseases,7,11,12 patients with any kind of severe immune-suppression,13
infantsaged lessthan1year,14,15olderpatientsagedmorethan65years,16ahigherscoreon
the American Society of Anaesthesiology (ASA) classification,16,17 and patients with a need
forsurgicalproceduresinmicrobiologicallycontaminatedareasasexpressedbytheprimary
wound contamination class.18(cid:1)20 Whenever staff recognizes one or more of the above men-
tionedriskfactors,anincreasedawarenessofpotentialSSIisnecessary.Inaddition,thereare
severalpatient-derivedriskfactorsthatcan,infact,bepositivelyinfluencedinprinciple.This
mayoftenbedifficult,butisstillworthwhileintermsofthepatient’soutcome.Thesemodifi-
ablecharacteristicswillbediscussedinmoredetailinthefollowingsections.
Overweight. Overweight patients with an increased body mass index (BMI) show high-
erSSI rates thando patientswith anormal body weight.13,17,21,22 In arandomized prospec-
tive study in a group of 1,032 patients, Beldi et al.23 showed that a BMI . 30kg/m2
doubledtheriskofanSSI.Tranetal.checkedforSSIriskfactors in969womenaftercesar-
ean section: every five-unit increment in the BMI increased the odds ratio (OR) for an SSI
by a factor of two.24 Yeung et al. recruited a consecutive cohort of 210 patients from vari-
cose vein surgery. Nine of 53 patients (17.0%) with a BMI $ 30kg/m2 suffered from an
I. INFECTIONCONTROLMEASURESFORTHEPREVENTIONOFSURGICALINFECTIONS