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Surgical Infections
Donald E. Fry
CHAPTER 1:
Microbiology of surgical pathogens
BACTERIA
FUNGI
VIRUSES
VIRULENCE FACTORS IN MICROORGANISMS
Structural components
Secreted toxins
Antimicrobial resistance
Genetics of resistance
Mechanisms of resistance
β-Lactams
Aminoglycosides
Tetracyclines
Trimethoprim–sulfamethoxazole
Erythromycin
Clindamycin
Vancomycin
Metronidazole
Quinolones
Other antibiotics
CHAPTER 2:
Antimicrobial agents
ANTIMICROBIALS – SPECTRUM OF ACTION
Antibiotic effect
Mechanisms of action of antibiotics
Antimicrobial resistance mechanisms
Antibiotic modification
Alterations of the targets of antibiotic agents
Active efflux of antibiotic
Prevention of antibiotic entry into the cell
Bypassing drug's action
Pharmacokinetics and pharmacodynamics of antimicrobial agents
SPECIFIC ANTIMICROBIALS
β-Lactam antibiotics
Penicillins
Cephalosporins
Monobactams
Carbapenems
Colistin
Aminoglycosides
Quinolones
Vancomycin and newer agents for MRSA infection
Vancomycin
Linezolid
Daptomycin
Tigecycline
Telavancin
Investigational semisynthetic glycopeptides
Dalbavancin
Oritavancin
Iclaprim
Tedizolid (TR-701)
CONCLUSION
CHAPTER 3:
Surgical immunology
INTRODUCTION
BASIC CELLULAR IMMUNOLOGY
Monocyte, macrophages, and dendritic cells
Monocytes
Macrophages
Dendritic cells
Function and regulation of monocytes, macrophages, and dendritic cells
Role of micro-RNAs in regulation of monocyte function
Polymorphonuclear leukocytes (neutrophils)
Neutrophil migration
Pathogen recognition
Phagocytosis and microbial killing
Other cell signaling
Neutrophil extracellular traps
Clinical implications from PMN-mediated lung injury
Mast cells, basophils, and eosinophils
LYMPHOCYTES
Tcells
Th cells (CD4+ T lymphocytes)
Regulatory T cells (Treg)
Killer cells
B lymphocytes
Differentiation and types of B cells
Development and function of B cells
IMMUNOGLOBULINS
THE INNATE IMMUNE RESPONSE
Sequence of events
Role of endothelium
Role of granulocytes and macrophages
Other cell types
Resolution of inflammation
Regulation of innate response
Autonomic nervous system and sex hormones
Apoptosis of immune cells
Systemic effects of inflammatory mediators
Acute phase response
THE ADAPTIVE IMMUNE RESPONSE
Humoral immunity
Activation of T and B cells
Exogenous protein antigens
B-cell response
Cell-mediated immunity
CONCLUSION
CHAPTER 4:
Surgical site infections
PATHOPHYSIOLOGY OF SSI
Inoculum of contamination
Clean operations
Clean-contaminated operations
Contaminated operations
Dirty operations
Virulence of contamination
Environment of the surgical site
Innate and acquired host defense
DIAGNOSIS AND SURVEILLANCE OF SSI
Diagnosis of SSI
Surveillance
PREVENTION OF SSI
Preoperative methods
Prehospitalization cleansing
Surveillance cultures
Preoperative hospitalization
Preoperative nursing home patients
Prior antibiotics
Intraoperative methods
Hair removal
Skin antiseptics
Air-handling systems
Operating room traffic
Adhesive drapes/wound sealants
Technical considerations
Drains
Delayed primary closure
Preventive antibiotics
Principle 1: The antibiotic must be in the tissues of the surgical site at the time of contamination
Principle 2: The antibiotic must have antimicrobial activity against the pathogens likely to be encountered
Principle 3: Continued antibiotic administration after wound closure has no impact on the frequency of SSIs
Preoperative colon preparation
What is the optimal MBP?
What is the best oral antibiotic choice?
What is the best timing for oral antibiotic administration?
Is C. difficile infection increased with the oral antibiotic bowel preparation?
Physiologic/Metabolic methods
Supplemental oxygen
Normothermia
Glycemic control
Postoperative prevention
MANAGEMENT OF SSIs
CHAPTER 5:
Skin, skin structure, and soft-tissue infections
ANATOMY OF THE SKIN
COMMON SKIN AND SKIN STRUCTURE INFECTIONS
Cellulitis
Erysipelas
Pyogenic SSSTIs
Human and animal bite infections
Hydradenitis suppurativa
NECROTIZING SOFT-TISSUE INFECTION
Clostridial NSTIs
Streptococcal NSTIs
Staphylococcal NSTIs
Polymicrobial NSTIs
OTHER PATHOGENS
CONCLUSION
CHAPTER 6:
Intra-abdominal infections
INTRODUCTION AND DEFINITIONS
Primary and catheter- related peritonitis
Secondary peritonitis
Tertiary peritonitis
Intra-abdominal abscess
Intra-abdominal phlegmon
PATHOPHYSIOLOGY
SOURCES OF IAIs
Appendicitis
Large and small bowel perforation
Gastroduodenal perforation
Biliary disease
Pancreatic and peripancreatic infection
Postoperative IAIs
MICROBIOLOGY
Microbiology of healthcare-associated IAIs
Susceptibilities of common pathogens
DIAGNOSIS
MANAGEMENT OF IAIs
Patient risk assessment
Physiological resuscitation and support
Source control
Source control for appendicitis
Source control for infected intra-abdominal fluid collections
Source control for generalized peritonitis
Antimicrobial therapy
Antimicrobial therapy for mild-to-moderate community-acquired IAIs
Antimicrobial therapy for severe community-acquired IAIs
Antimicrobial therapy in healthcare-associated IAIs
Duration of antimicrobial therapy
CLINICAL OUTCOMES
CHAPTER 7:
Perirectal abscesses and pilonidal disease
PERIRECTAL ABSCESSES
Treatment
RECURRENT ABSCESSES AND FISTULAS
Special considerations
Intersphincteric abscesses
Submucosal abscess
Supralevator abscess
Horseshoe abscess
Postoperative care
Massive perineal infection and soft-tissue necrosis
Crohn disease
Leukemic and granulocytopenic patients
HIV-positive and AIDS patients
PILONIDAL ABSCESS
CONCLUSIONS
CHAPTER 8:
Hospital-acquired and ventilator-associated pneumonia
RISK FACTORS
PATHOGENESIS
PREVENTION
Tracheostomy
DIAGNOSIS
Ventilator-associated tracheobronchitis
TREATMENT
CHAPTER 9:
Postoperative urinary tract infections
DEFINITION AND DIAGNOSIS
EPIDEMIOLOGY
PATHOPHYSIOLOGY
TREATMENT
PREVENTION
CONCLUSION
CHAPTER 10:
Catheter-related bloodstream infections
INTRODUCTION
EPIDEMIOLOGY
PATHOPHYSIOLOGY
MICROBIOLOGY
The special problem of MRSA CRBSIs
Reduction of CRBSIs in the ICU: The Keystone Project
PREVENTION OF CRBSIs – EVIDENCE-BASED GUIDELINES
Education, training, and staffing
Selection of catheters and sites
Peripheral catheters
Central venous catheters
Hand hygiene and aseptic technique
APPROACH TO THE FEBRILE PATIENT WITH A LONG-TERM INDWELLING VASCULAR CATHETER
Making a definitive diagnosis of CRBSIs
Indications for catheter removal (Figure 10.1)
Duration of antibiotic therapy
CONCLUSION
CHAPTER 11:
Clostridium difficile infection
PATHOGENESIS
RISK FACTORS
DIAGNOSIS
PREVENTION
TREATMENT OF CDIs
Recurrent infection
TREATMENT IMPLICATIONS FOR SURGEONS
Community-acquired CDIs
Fulminant CDIs
Surgical management
CONCLUSION
CHAPTER 12:
Burn wound infections
PATHOBIOLOGY OF THE BURN WOUND
RECOGNITION AND DIAGNOSIS OF INFECTION IN THE BURN WOUND
Use of burn wound cultures
Definitions for the burn patient
Burn wound impetigo
Burn wound colonization
Burn wound infection
Invasive burn wound infection
Toxic shock syndrome
BACTERIA AND THEIR TREATMENT
Gram-positive organisms
Gram-negative organisms
Anaerobes
Fungi: Yeasts and molds
Viral infection of the burn wound
Tetanus
TOPICAL ANTIMICROBIAL COMPOUNDS AND AGENTS
Sodium hypochlorite (NaOCl)
Silver nitrate (AgNO3)
Silver sulfadiazine
Mafenide acetate (Sulfamylon)
Povidone–iodine (Betadine)
Gentamicin sulfate (Garamycin)
Bacitracin/polymyxin (Polysporin)
Nitrofurantoin (Furacin)
Mupirocin (Bactroban)
Acticoat A.B.
Nystatin (Mycostatin, Nilstat)
INFECTION CONTROL BEST PRACTICE
CHAPTER 13:
Fungal infections of surgical significance
CANDIDA INFECTIONS
Epidemiology of candida infections
Microbiology of candida infection
Pathogenicity and virulence factors for Candida spp.
Clinical aspects of candida infection
Candida prophylaxis
Management of specific infections
Candidemia
Choice of antifungal
Duration of therapy
Candidemia in non-neutropenic patients
Suppurative thrombophlebitis
Peritonitis and Intra-abdominal abscess
Urinary tract infection
COMMUNITY-ACQUIRED FUNGAL PATHOGENS
Blastomycosis
Pathogenesis
Diagnosis
Treatment
Coccidioidomycosis
Diagnosis
Treatment
Cryptococcal infections
Pathogenesis
Diagnosis
Treatment
Histoplasmosis
Pathogenesis
Diagnosis
Treatment
Paracoccidioidomycosis
Pathogenesis
Diagnosis
Treatment
Sporotrichosis
Pathogenesis
Diagnosis
Treatment
NON-CANDIDA HEALTHCARE-ASSOCIATED INFECTIONS
Aspergillus fumigatus
Mucormycosis
Pathogenesis
Diagnosis
Treatment
Pneumocystis pneumonia
ANTIFUNGAL AGENTS
Amphotericin B deoxycholate
5-Fluorocytosine
Azole antifungal drugs
Echinocandins
CHAPTER 14:
Viral infections of surgical significance
HUMAN IMMUNODEFICIENCY VIRUS
HEPATITIS
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
Other hepatitis viruses
HUMAN PAPILLOMAVIRUS
Anogenital HPV
Cervical carcinoma
Vulvovaginal carcinoma
Male genital carcinoma
Anal carcinoma
Genital warts
Aerodigestive tract HPV infection
Non-genital cutaneous HPV infection
HUMAN HERPESVIRUSES
HHV-1 (herpes simplex)
HHV-2 (genital herpes)
HHV-3 (varicella-zoster)
HHV-4 (EBV)
HHV-5 (cytomegalovirus)
HHV-6
HHV-7
HHV-8
POLYOMA VIRUSES
BK polyoma infection
JC polyoma infection
Rabies
CHAPTER 15:
Cardiothoracic surgical infections
THORACIC EMPYEMA
Definition
Clinical presentation and diagnosis
Pathogenesis and bacteriology
Prevention
Supportive measures
Antibiotic treatment
Drainage procedures
Intrapleural fibrinolytic therapy
Surgical treatment
STERNAL WOUND INFECTIONS
Definition
Incidence
Pathogenesis and bacteriology
Prevention
Clinical presentation and diagnosis
Treatment
INFECTIONS OF THE MEDIASTINUM
Anatomic considerations of the mediastinum
Descending necrotizing mediastinitis
Etiology and incidence
Diagnosis
Treatment
Esophageal perforation
Etiology and incidence
Diagnosis
Treatment
Nonsurgical management
Surgical management
Results of treatment
Chronic fibrosing mediastinitis
INFECTIVE ENDOCARDITIS
Pathogenesis
Host susceptibility
Bacteriology
HCA endocarditis
PVE
Diagnosis
Blood cultures
Echocardiography
Coronary angiography.
Diagnosis criteria of IE
Medical management
Outcome considerations
Surgical management
Special situations
Surgical outcome
Long-term outcome of IE
Prophylaxis
CHAPTER 16:
Head–neck infections
CERVICAL SPACE INFECTION
Anatomy
Superficial and deep cervical fascial planes
Suprahyoid spaces
Entire length-of-neck spaces
Infrahyoid space
Risk factors
Diagnosis
Imaging studies
Microbiology
Treatment
Airway management
Antibiotic management
Surgical management
Complications
NOSOCOMIAL SINUSITIS
Anatomy
Risk factors, pathogenesis, and bacteriology
Diagnosis
Prevention and treatment
Complications
PAROTITIS
Anatomy
Risk factors
Pathogenesis and microbiology
Diagnosis
Treatment
MIDFACIAL CELLULITIS
Primary cellulitic infections
Secondary cellulitic infections
Treatment
Complications
ODONTOGENIC INFECTIONS
Pathogenesis
Risk factors
Microbiology
Diagnosis
Treatment
Complications
CHAPTER 17:
Vascular surgical site infection
EPIDEMIOLOGY OF VASCULAR SITE INFECTION
RISK FACTORS FOR VASCULAR INFECTION
TREATMENT OF VASCULAR GRAFT INFECTIONS
Antibiotic therapy
Patient selection for in situ graft replacement
PREVENTIVE MEASURES
CONCLUSION
CHAPTER 18:
Urological infections
PYELONEPHRITIS
RENAL ABSCESS/PERINEPHRIC ABSCESS
EMPHYSEMATOUS PYELONEPHRITIS/PYELITIS
MANAGEMENT OF URINARY INFECTION WITH OBSTRUCTION
EPIDIDYMO-ORCHITIS
PROSTATITIS/PROSTATE ABSCESS
NECROTIZING FASCIITIS (FOURNIER GANGRENE)
CHAPTER 19:
Bone and joint infections
INTRODUCTION
PATHOGENESIS
Microorganism factors
Local and systemic host factors
DIAGNOSIS OF BONE AND JOINT INFECTIONS: AN OVERVIEW
Clinical findings
Laboratory tests
Imaging modalities
Histopathology
Microbiological methods
Molecular methods
PEDIATRIC SEPTIC ARTHRITIS AND OSTEOMYELITIS
Epidemiology and pathogenesis
Diagnosis
Treatment
SEPTIC ARTHRITIS IN ADULTS
Epidemiology and pathogenesis
Diagnosis
Treatment
ADULT OSTEOMYELITIS
PREVENTION OF INFECTION IN OPEN FRACTURES
Antibiotic therapy in open fractures
Debridement
Wound management
Fracture stabilization
Specialized procedures
POST-TRAUMATIC OSTEOMYELITIS
PERIPROSTHETIC JOINT INFECTIONS
Epidemiology and pathogenesis
Diagnosis
Treatment
CHAPTER 20:
Obstetric and gynecological infections
VULVAL INFECTIONS
Cellulitis
Furuncles
Carbuncles
Abscesses
Labial abscess
Bartholin gland abscess
Hidradenitis suppurativa
Skene gland abscess
POSTOPERATIVE INFECTIONS
Vaginal microflora
Surgical site infection
Postpartum endometritis
Risk factors
Clinical presentation and diagnosis
Management
Episiotomy infections
Postoperative pelvic infection
CHAPTER 21:
Necrotizing enterocolitis
PATHOPHYSIOLOGY
Immature intestinal barrier
Role of enteral feeding
Immunoglobulins
Abnormal bacterial colonization
Inflammatory mediators and NEC
DIAGNOSIS
Clinical
Laboratory findings
Radiographic
Differential diagnosis
PATHOLOGY
TREATMENT
Medical management
EXPERIMENTAL AND EMERGING SCIENCE ON TREATMENT
Probiotics
Growth factor receptors
Surgical management
Indications for surgery
Surgical approaches
COMPLICATIONS
Acute
Chronic
CHAPTER 22:
Postoperative infections of the central nervous system
SPECIAL CONSIDERATIONS OF CNS INFECTIONS
OVERVIEW OF RISK FACTORS FOR POSTOPERATIVE CNS INFECTIONS
POSTOPERATIVE CRANIAL INFECTIONS
Meningitis
Subdural empyema
EPIDURAL INFECTIONS AND OSTEOMYELITIS OF THE BONE FLAP
Brain abscess
Shunt infections
POSTOPERATIVE SPINE INFECTIONS
Risk factors for infections after spinal surgery
Prevention
Diagnosis
Treatment
CHAPTER 23:
Bioterrorism
ANTHRAX
Plague infection
Tularemia
Brucellosis
Cholera
Q fever
Glanders
VIRUSES
Smallpox
Equine encephalitis virus
Viral hemorrhagic fever
BIOLOGICAL TOXINS
Botulinum toxin
Ricin
Other microbial toxins
RECOGNITION OF BIOTERRORISM
CHAPTER 24:
Microbial translocation, gut origin sepsis, probiotics, prebiotics, selective gut decontamination
INTRODUCTION
BACTERIAL TRANSLOCATION AND GUT-ORIGIN SEPSIS: A HISTORICAL PERSPECTIVE
THE INTESTINAL BARRIER: DEFENSES AND MECHANISMS
THERAPEUTIC OPTIONS AND APPROACHES
Prevention
Therapies directed at maintaining a stable gut flora
Probiotics, prebiotics, and synbiotics
Selective digestive tract decontamination
Therapies direct at supporting gut barrier function
CONCLUSION
CHAPTER 25:
Sepsis: systemic inflammation and organ dysfunction
SEPSIS: THE EVOLUTION OF A CONCEPT
Host–microbial interactions in evolution
Evolving concepts of sepsis
From sepsis to organ dysfunction
EPIDEMIOLOGY OF SEPSIS, SIRS, AND MODS
THE BIOLOGY OF THE INFLAMMATORY RESPONSE
Recognition of danger
Modulation of gene expression after receptor engagement
Apoptosis in sepsis and systemic inflammation
Early mediators of inflammation
Late mediators of inflammation
THE CLINICAL PHENOTYPE OF THE INFLAMMATORY RESPONSE
Cardiovascular alterations
Metabolic alterations
Immunological alterations
THE MULTIPLE ORGAN DYSFUNCTION SYNDROME
Respiratory dysfunction
Cardiovascular dysfunction
Renal dysfunction
Gastrointestinal dysfunction
Neuromuscular dysfunction
Hematological dysfunction
Measuring the severity of organ dysfunction
The iatrogenic roots of MODS
MANAGEMENT OF SEPSIS
Resuscitation of the septic patient
Diagnosis and treatment of infection
Support of the septic patient
TARGETING THE MEDIATORS OF SYSTEMIC INFLAMMATION
Endotoxin
Tumor necrosis factor
Interleukin-1
Activated protein C
Corticosteroids
Intravenous immunoglobulin
Other approaches and the failure of sepsis trials
CONCLUSIONS
INDEX
TOC
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