Surgical Infections Donald E. Fry
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1SURGICAL INFECTIONS2
3SURGICAL INFECTIONS
Donald E. Fry,MD Adjunct Professor of Surgery Northwestern University Feinberg School of Medicine Chicago, Illinois Emeritus Professor of Surgery University of New Mexico School of Medicine Albuquerque, New Mexico USA
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5Preface
The management of infection has a long history and continues to be a major challenge for surgeons in all specialties, for whom infectious disease had its earliest major relevance in the management of battlefield casualties. Ambroise Paré identified that the topical treatment of traumatic wounds influenced the outcome. His substitution of a turpentine-based topical treatment, as opposed to the boiled oil and cauterization method, was a beginning for antisepsis at the injury site. In the 17th century, Leewenhoek first observed bacteria and became the ‘Father of Microbiology’. Bacteria were not viewed as being of pathologic significance at that time. In the 18th century, the Scottish surgeon John Hunter observed the value of open management and delay closure of battlefield wounds, an observation that should be remembered today.
The 19th century saw significant progress in understanding and managing infections of the surgical patient. The Hungarian Semmelweis, working at the Vienna General Hospital, identified the role of obstetricians in potentially introducing a toxin or poison into birthing women with the pre-partum pelvic examination. He studied the benefits of hand-washing with sodium hypochlorite solution and demonstrated a reduction in the rate of what was called ‘child bed fever’. Of course, the germ theory of disease was not yet formulated and an infectious agent (Streptococcus pyogenes as it turned out) was not suspected. Despite clinical evidence of benefit, the work of Semmelweis was not accepted at the time.
It was Louis Pasteur who developed the germ theory of disease, which largely originated in his work on the bacterial contamination of French wine and his studies of silkworm infections. He proposed microbes as infectious pathogens in man but unfortunately a stroke prevented him from claiming the scientific achievement of proving his theory. Nevertheless, his contributions subsequently led to the development of the rabies and anthrax vaccines. Perhaps his ultimate contribution was the Pasteur Institute, which prospers to this day, with original research into infection and the host response. Elie Metchnikoff was one of the first appointees at the Pasteur Institute, and is generally credited with being the father of immunology. Metchnikoff earned the Nobel Prize in 1908 for the discovery of phagocytic cells.
Robert Koch, a German physician, developed the scientific evidence to prove the germ theory and the internationally recognized Koch postulates. His early research with anthrax in the 1870s was conducted in a home laboratory using a microscope given to him by his wife. He discovered Mycobacterium tuberculosis in 1882, for which he received the Nobel Prize in 1905.
With the dawn of the 20th century came the hope that specific treatments could be developed to treat specific infections. Paul Ehrlich discovered salvarsan as a treatment for syphilis. With this first treatment for an established bacterial infection, Ehrlich's work led to the concept of the ‘magic bullet’ that would be microbe specific and eradicate infection. This was conceptually different from the Pasteur and Metchnikoff idea of host enhancement through vaccines.
The discovery of penicillin and the development of sulfa compounds in the late 1920 and 1930s resulted in specific chemotherapy (Ehrlich's term) becoming the mainstay for the treatment of infection. Thus, after World War II, antibiotics were widely deployed for the treatment of infection, with different antibiotics used against different organisms. Microbial resistance patterns developed for specific pathogens and this required the development of newer drugs, or the re-engineering of older ones.
The treatment of clinical infections largely became the purview of internal medicine practitioners. It was William Altemeier who pioneered interest in the treatment and prevention of infectious problems that were unique to the surgical patient. In the 1950s, Altemeier and others began to look at antibiotics as a potential avenue not only to treat infection, but to prevent infections in the patient undergoing invasive procedures. However, early clinical trials failed to show any clinical benefit. The shortcomings of these early trials were due to very heterogeneous patient populations, but more importantly to the fact that the antibiotics were not initiated until the postoperative period. Ashley Miles at the Lister Institute in London became the father of preventive antibiotics in surgery, by conducting basic experimental studies in 1957 with John Burke from Boston, which demonstrated that the antibiotics needed to be given before the insult to achieve benefit. In 1969 Hiram Polk provided the critically stratified, prospective, randomized clinical trial to provide proof of concept. Thus, the use of antibiotics and the evolution of preventive strategies became commonplace in surgical care. The work of all of these international investigators led to the establishment of the Surgical Infection Society of North America, The Musculoskeletal Infection Society, The Surgical Infection Society of Europe, and the Japan Society for Surgical Infection.
The management of the infectious disease problems covered in this book form an integral part of surgeons' clinical duties. First, there is the patient who presents with a community-acquired infection. These infections commonly include soft tissue infections following traumatic injury (chapter 5) or intra-abdominal infections after perforation of a viscus (chapter 6). They may include brain abscess (chapter 22), empyema from pneumonia (chapter 15), or osteomyelitis (chapter 19). In community-acquired infection, treatments require combinations of surgical management of the primary focus of infection, antimicrobial therapy for the offending micro-organisms, and supportive care to manage physiologic perturbations created by the infectious event.
Second, surgical site infection (SSI) continues to be a complication of care that has defied control (chapter 4). SSI rates have dramatically improved since the times of Ambroise Paré and Joseph Lister. However, the design of surgical interventions has become more innovative with transplantation procedures, 6extensive surgical oncology efforts, and the general deployment of prosthetic materials to replace effete tissues. The surgical host has clearly become more susceptible, with increasing age at the time of intervention, more advanced diseases at the time of operation, and immunosuppression either associated with therapeutic interventions (e.g. corticosteroids) or loss of homestasis (e.g. trauma, shock, resuscitation). While progress has been made in the prevention of SSI, newer methods and strategies are needed.
Third, nosocomial infections of the surgical patient at anatomic sites remote from the operation have continued to complicate surgical care. The surgical intensive care unit (ICU) has provided dramatic support for critically ill patients, but has become a reservoir of increasingly resistant pathogens. Support technology has yielded endotracheal tubes (chapter 8), intravenous infusion sites and arterial lines (chapter 10), drainage catheters (chapter 9), and many other invasive devices that serve an important support function but which have become portals for microbial access to the host. Not only has our invasive support technology created the opportunity for infection, but systemic antibiotic treatment has changed the ecology of the host to one where resistant bacteria are the rule and not the exception. Thus, meticillin-resistant Staphylococcus aureus, extended-spectrum β-lactamase Gram-negative bacteria, and Clostridium difficile have become common problems of hospital-acquired infection for surgical patients.
The prevention and management of surgical infection has become a part of the management for every patient that has a surgical procedure, and justifies books that, like this one, attempt to address all of these contemporary issues. The role of infection and surgery is a dynamic one that is constantly changing. Who would have believed 40 years ago that peptic ulcer disease was an infection of the gastric mucosa with Helicobacter pylori? Over the last 40 years, community-acquired staphylococcal infections have been transformed from being penicillin-sensitive to being meticillin-resistant. Bacterial infections in the ICU are now commonly pan-resistant to virtually all available antibiotics. Fungal infections are all too common in severely ill surgical patients but were barely identified 40 years ago. The future of head and neck cancer is likely to be more commonly associated with human papilloma virus infection and not tobacco-associated. Finally, contagious disease has now been associated with misfolded neuroproteins (new-variant Creutzfeldt – Jakob disease) rather than nucleotide-bearing pathogens such as bacteria, fungi, or viruses. Indeed, the germ theory of disease may be returning to theory status.
Reflections on changes in infectious diseases within a surgical setting over the last 40 years can only beg the question: ‘What will happen in the next 10 or so years as we go forward?’ How will a text on surgical infections change over the next decade? Many of the following may occur, with some being more likely than others:
It is certain that prevention and management of infection in the surgical patient will remain a challenge. We trust that the many contributions to Surgical Infections will have a useful role as we all move forward from this point in time.
Donald E. Fry
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9Contributors 12Dedication
To Hiram C. Polk, Jr, M.D.
In recognition of his lifetime contribution to surgical education and research in the science of surgical infection