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PubMed2000

Overview of resistant gram-positive pathogens in the surgical patient.

Staphylococci and enterococci are the most common pathogens in surgical-site and bloodstream infections. The emergence of drug resistance among these gram-positive bacteria thus poses a substantial threat to patients with surgical infections. Resistance to methicillin/oxacillin is frequently observed in Staphylococcus aureus isolates and is often accompanied by multidrug resistance. Vancomycin is usually the treatment of choice for infections caused by methicillin-resistant S. aureus (MRSA), so the recent appearance of S. aureus isolated with intermediate sensitivity to vancomycin is cause for concern. Vancomycin resistance has already appeared in most species of enterococci. Infections caused by vancomycin-resistant enterococci (VRE) are associated with increased mortality compared to infections caused by vancomycin-sensitive isolates. Measures for preventing vancomycin resistance include reducing the use of vancomycin and other agents that appear to be associated with VRE, including third-generation cephalosporins and anti-anaerobic drugs. Third-generation cephalosporins have also been implicated in the increased prevalence of MRSA infections. Prudent use of existing antibiotics is an essential strategy for combating the rising tide of drug-resistant gram-positive pathogens.

Cross Infection↗
PubMed2001

The importance of beta-lactamase resistance in surgical infections.

Substantial costs are associated with the treatment of nosocomial infections, 2 million cases of which occur annually in the United States. Hospital-acquired, gram-negative infection has become an increasing problem, particularly in the intensive care unit where up to 40% of the most frequently isolated strains of Enterobacteriaceae are resistant to standard beta-lactam antibiotics. Among several mechanisms of acquisition of resistance, beta-lactamase production accounts for a high percentage of treatment failures and relapses. By the end of the 1980s, some 10-30% of all nosocomial infections were caused by type-1 beta-lactamase-producing gram-negative isolates, and Enterobacter species had emerged as a major resistant pathogen. The beta-lactam/beta-lactamase inhibitor combinations, such as ampicillin/sulbactam, represent an innovative approach to the problem of beta-lactamase-mediated resistance. Clinical use of these agents has been associated with low rates of resistance and new data suggest they may have a specific role in controlling the emergence and spread of nosocomial infections.

Cross Infection↗
PubMed2001

The role of beta-lactam/beta-lactamase inhibitor combinations in surgical infections.

Many surgical infections are characterized by synergistic polymicrobial mixed infection, for which broad-spectrum antimicrobial therapy is usually administered on an empiric basis. Until relatively recently, standard empiric therapeutic regimens have involved the use of two or more antibiotics, such as aminoglycosides and anti-anaerobic agents, to achieve adequate aerobic and anaerobic coverage. There are often substantial drawbacks, however, such as drug-induced toxicity and high costs of treatment. Evidence from a number of clinical studies suggests that single-agent therapy with beta-lactam/beta-lactamase inhibitor combinations is a suitable and cost-effective alternative to multidrug regimens, as well as to monotherapy with cephalosporins or carbapenems in the treatment of intra-abdominal, gynecologic, and diabetic foot infections, and brain abscesses. These agents are also suitable for use in perioperative prophylaxis and may offer benefits over other agents in terms of reduced incidence of surgical wound infections and lower costs.

Anti-Bacterial Agents↗
PubMed2001

Basic aspects of and general problems in surgical infections.

Antibiotics are important in the prophylaxis and treatment of surgical infections as well as in the management of nosocomial infections acquired postoperatively in surgical patients. Surgeons encounter a range of infectious conditions, including established single-pathogen infections of soft tissues, polymicrobial intra-abdominal infections, and resistant gram-negative nosocomial infections such as ventilator-associated and aspiration pneumonia. Preoperative antibiotic administration has been shown to reduce the risk of surgical site infections and is now an accepted part of the standard care for most surgical patients. In patients with established single-pathogen or polymicrobial infections requiring surgery, studies have shown appropriate empiric antibiotic therapy to be an important adjunct to surgical intervention and general supportive measures in improving patient outcome. Antibiotics are also essential for those who develop postoperative nosocomial infections. Empiric coverage of the most likely causative organisms, especially in synergistic polymicrobial mixed infections, is one of the keys to successful prophylaxis and treatment of surgical infections.

Anti-Bacterial Agents↗
PubMed2005

Gut bacterial translocation and postoperative infections: a prospective study in schistosomotic patients.

BACKGROUND: Bacterial translocation (BT) across the intact intestinal mucosal barrier has been postulated as a source of sepsis in susceptible patients, including those with cirrhosis and portal hypertension. This condition has not been studied in hepatosplenic schistosomiasis, wherein portal hypertension and the presence of an immune deficiency state associated with the parasitic disease could predispose to BT into mesenteric lymph nodes (MLN). A study was conducted to determine the prevalence of aerobic bacteria in MLN (bacterial translocation) of patients with hepatosplenic schistosomiasis, and establish a possible association with postoperative infections. METHODS: In a series of 51 patients submitted to surgical treatment of schistosomotic portal hypertension with splenectomy and gastric devascularization, MLN were obtained from each patient at the beginning (MLN1) and at the end (MLN2) of the surgical procedure, and sent for bacteriological analysis. Prospective patient evaluation during the postoperative period correlated positive MLN cultures with infectious complications. RESULTS: The prevalence of aerobic bacteria was 17.6% at MLN1 and 27.5% at MLN2, however, this difference was non-significant (p = 0.24). Bacterial translocation to all MLN was 22.5%. Escherichia coli was the most frequent organism (26.1%, 6/23). The overall incidence of postoperative infections was 19.6% (10/51), with a significant association with the presence of positive cultures of MLN (p = 0.043). CONCLUSIONS: The findings of this study suggest that the presence of aerobic bacteria on MLN as a consequence of BT may play a role in the development of postoperative infectious complications, particularly in schistosomotic patients.

Adult↗
PubMed2006

Risk factors for surgical infections.

BACKGROUND: Many risk factors for postoperative infections have been identified that can be used individually or in combination as scoring indices. METHODS: Infection risk scores can be applied in clinical practice to identify high-risk surgical patients, to indicate the need to implement risk-reduction strategies, and to stratify risk for comparison of outcome among different patient series. RESULTS: In the hierarchy of patient-related risk factors, serum albumin concentration and advanced age rank at the top of the list. Among the treatment-related factors, the quality of the surgical technique is a most important determinant, although most surgical site infections are attributable to patient-related risk factors rather than to flawed surgical care. Scoring systems can identify the patients at highest risk, thus prompting the implementation of therapy to improve modifiable conditions, but most clinicians outside the academic and research setting do not use them. Risk assessment also can be performed by expert clinical judgment. Discussion with the patient and informed consent are essential. CONCLUSIONS: Carefully collected scores of patient risk factors may be valuable to document the relations between the risk and the outcome of surgery. Ideally, each institution should select a validated scoring system to audit postoperative infectious morbidity and surgical performance in the various specialties.

Aged↗
PubMedDate not supplied

Antimicrobial prophylaxis: a critique of recent trials.

Most evaluations of antimicrobial prophylaxis have serious defects in design or fail to assess the clinical importance of observed differences. Reports that were published in the last decade and that meet stringent criteria indicate that antimicrobial prophylaxis is justified in few circumstances and nearly always only in very short courses, often just a single dose. These situations include vaginal hysterectomies (cephalosporin or penicillin), total abdominal hysterectomies (cephalosporin), high-risk cesarean sections (cephalosporin), elective colorectal surgery (oral erythromycin-neomycin, kanamycin-metronidazole, or doxycycline), vascular grafts of the abdominal aorta or lower extremity vasculature (cephalosporin), total hip replacement (cephalosporin or penicillinase-resistant penicillin), head and neck cancer surgery (cephalosporin), travelers' diarrhea (doxycycline), prevention of pneumonia due to Pneumocystis carinii in susceptible cancer patients (trimethoprim-sulfamethoxazole), and recurrent urinary tract infections in females (trimethoprim-sulfamethoxazole). Elective high-risk gastric and biliary tract surgery and prosthetic cardiac valve replacement may also merit prophylaxis, but the information is less conclusive.

Anti-Bacterial Agents↗
PubMed2002

Adverse events in surgical patients in Australia.

OBJECTIVE: To determine the adverse event (AE) rate for surgical patients in Australia. DESIGN: A two-stage retrospective medical record review was conducted to determine the occurrence of AEs in hospital admissions. Medical records were screened for 18 criteria and positive records were reviewed by two medical officers using a structured questionnaire. SETTING: Admissions in 1992 to 28 randomly selected hospitals in Australia. STUDY PARTICIPANTS: Five hundred and twenty eligible admissions were randomly selected from in-patient database in each hospital. A total of 14,179 medical records were reviewed, with 8747 medical and 5432 surgical admissions. MAIN OUTCOME MEASURES: Measures included the rate of AEs in surgical and medical admissions, the proportion resulting in permanent disability and death, the proportion determined to be highly preventable, and the identification of risk factors associated with AEs. RESULTS: The AE rate for surgical admissions was 21.9%. Disability that was resolved within 12 months occurred in 83%, 13% had permanent disability, and 4% resulted in death. Reviewers found that 48% of AEs were highly preventable. The risk of an AE depended on the procedure and increased with age and length of stay. CONCLUSION: The high AE rate for surgical procedures supports the need for monitoring and intervention strategies. The 18 screening criteria provide a tool to identify admissions with a greater risk of a surgical AE. Risk factors for an AE were age and procedure, and these should be assessed prior to surgery. Prophylactic interventions for infection and deep vein thrombosis could reduce the occurrence of AEs in hospitals.

Adolescent↗
PubMed1990

Are in-hospital deaths and long stay markers for errors in surgery?

To test the feasibility of using a system for classification of surgical errors and of in-hospital deaths and long hospital stay as markers for errors in surgery we reviewed the hospital records of 273 patients with 285 admissions. During the one year study period there were in all 3767 patients admitted for surgical care. From these we selected the 131 who died in the department during the year, the 100 who had the longest stay (greater than 33 days) and the 91 patients were referred to the departments of internal medicine, infectious diseases or orthopedic surgery. Errors were classified as error of omission or commission, in diagnosis or in therapy. Possible or definitive errors were found in the care of 23% of the patients who died and in 10% of the ones with a long hospital stay. Only 3% of patients referred to other departments experienced errors. It is concluded, that "in-hospital death and "long hospital stay" can be used as markers to identify errors in surgery.

Adolescent↗
PubMed1980

A method for classifying patients according to the nosocomial infection risks associated with diagnoses and surgical procedures.

To compare validly the nosocomial infection rates (NIRs) in groups of patients studied from different time periods and/or different hospitals, one must control for the important factors that influence a patient's susceptibility to infection. The authors developed a method for assessing one component of nosocomial infection risk, based on patients' diagnoses and surgical procedures. This method classifies patients according to their risk of developing a nosocomial infection at each of four infection sites and at all four sites combined. Applying the method to data collected on 136,516 patients from 276 hospitals studied in the SENIC Project (Study on the Efficacy of Nosocomial Infection Control), the authors found that NIRs increased according to the predicted ranking of risk categories, even when the analyses were stratified individually by age, sex, hospital service and exposure to urinary catheterization or continuous ventilatory support. Depending on the site of infection, the rate increased as much as 100-fold from low-risk to high-risk categories. The data indicate that infection risk as assessed with this classification method will account for some of the variation in NIRs due to differences in patients' clinical conditions. Further analyses using multivariate techniques must be performed to explore in detail the relative importance of this risk classification in comparison with other risk factors and to determine which factors must be controlled in SENIC analyses.

Adolescent↗