Infectious Disease Compendium

Wound Infection

Diagnosis

Rubor, dolor, calor, and tumor in a surgical site. There can be a cellulitis or an abscess.

Epidemiologic Risks

Having surgery. It is safe to say that if your institution is doing everything right: SCIP, hand hygiene etc., surgical infections should be very close to zero and any excuse that 'our patients are sicker' is a lame excuse by the lazy and deluded to avoid the hard work it takes to prevent infections.

Risks include shaving instead of clipping the surgical site, post operative hypothermia, poor perioperative diabetes control, post operative hypoxia, and failure to give prophylactic antibiotics (try to give within 18 minutes of cut time (PubMed)).

Studies are variable in efficacy for treating MRSA colonization, but in screening for any S. aureus (MRSA & MSSA) nasal colonization and decolonizing, infections dropped in half (PubMed).

Also, if your surgeon is not using Chlorhexidine-Alcohol for preop, don't be surprised in they have infections (PubMed).

If you are worried about MRSA and give Vancomycin as a preventative, give Cefazolin as well. Vancomycin has an increase in MSSA infections, it is such a lousy drug (PubMed).

Microbiology

Usually Streptococci (esp. S. pyogenes) and Staphylococcus aureus. If intra-abdominal surgery, mixed infections may result.

Empiric Therapy

Cefazolin OR nafcillin / oxacillin OR vancomycin depending on allergies and local resistance patterns.

As a rule, gram negative aerobic rods and anaerobes only grow in dead meat or abscesses from intra-abdominal surgery. In that case surgery is the answer, in the meantime I prefer a third generation cephalosporins PLUS metronidazole.

Alternatives include a carbapenem OR penicillin/beta-lactamase inhibitors OR a quinolone PLUS (metronidazole OR clindamycin).

Pearls

When in doubt, open up the wound. Toxic shock syndrome can be a complication as well.

Wound care? It seems to be more tradition that science. I was told as a medical student never to put in a wound what you wouldn't put in your eyes, so I pack wounds with soft contact lenses. I like honey and sugar (really) and wound vacs. Otherwise it is a matter of keeping them clean and moist.

In perforated appendicitis, "Study patients were randomized to the control arm (loose wound closure with staples every 2 cm) or the WPP arm (loosely stapled closure with daily probing between staples with a cotton-tipped applicator until the wound is impenetrable). Intravenous antibiotic therapy was initiated preoperatively and continued until resolution of fever and normalization of the white blood cell count. ...The patients in the WPP arm had a significantly lower SSI rate (3% vs 19%; P = .03) and shorter hospital stays (5 vs 7 days; P = .049) with no increase in pain (P = .63) (PubMed). "

Rants