Surgical Infectious Disease. Extra Credit Questions
EXTRA-CREDIT QUESTIONS
25. Should all patients undergoing elective laparotomy receive prophylactic antibiotic coverage?
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No. Doing so would contribute to driving up the cost of antibiotics and their complication rate and devaluing formerly good drugs by rendering them useless against common flora against which they were once highly potent. Operating room nurses have always classified the kind of operation by its status with respect to microbial exposure: clean, contaminated, or septic. These categories are approximation of the microbial risk exposure, and if additionally are superimposed categories of patient resistance (higher risk associated with aging, obesity or other malnutrition, concomitant drugs, or viral or mycobacterial or neoplastic disease immune compromise), these same strata are called class I, II, and III.
26. Which abscess is the most important one to be drained?
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It is the last abscess that counts in drainage because the patient’s dramatic response is often only achieved when the last pus is drained. Draining a pelvic abscess, for example, but leaving behind a subphrenic abscess, would not result in the quenching of the inflammatory mediators of the sepsis syndrome.
27. Is postoperative fever the earliest and most frequent sign of an incisional infection? Show answer
Postoperative fevers are much more frequent than are wound infections, and the typical wound infection presents far later. The principal sources of postoperative fever are:
* Wind (atelectasis or pneumonia)
* Water (urinary tract infection)
* Walk (get your patient up and around; thrombophlebitis)
* Wound
28. Should you begin amphotericin at the first isolation of Candida species drawn from any intravenous catheter line?
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No. Again, remember the distinction between colonization and infection, as well as the source from which the specimen is taken. The IV lines through which hyperalimentation solutions are infused make colonization possible. The presence of a fungus such as Candida species is frequent in patients who do not have an invasive fungal infection or a true candidemia. The latter might be distinguished from catheter colonization by a blood culture drawn from another source, such as a venopuncture. If evidence of any invasive fungal infection is also present (e.g., as endoscopic biopsy of inflammatory mucositis), a choice of antifungal therapies is now indicated.
Topical fungal solutions (e.g., mycostatin mouthwashes or lavage) may control the local fungal infection and may sometimes be instituted as prophylaxis in high-risk patients (e.g., patients on antirejection therapy for bone marrow or solid organ transplantation).
Systemic antifungal agents include fluconazole, caspifungin, and amphotericin.
29. Are antibiotic drug combinations always superior to a single antibiotic agent?
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Monotherapy is superior to combination antibiotic treatment regimens, but this is provable probably only in the highest-risk patients. With the carbapenem class antibiotic agents, a large multicenter clinical trial proved imipenem therapy superior to aminoglycoside and a macrolide antibiotic, with survival demonstrably superior only in the patients with the highest APACHE scores. Ertapenem monotherapy was the equivalent of ceftriaxone and metronidazole in a smaller, more recent trial.
More is not always better, and the R and S on culture reports does not translate directly to the M and M (morbidity and mortality) at the Death and Complications Conference reports. It is not just important that the effective antibiotic regimen kills the bacteria; also important are how this microbicidal effect is carried out and what effect it may have on the patient in quenching or prolonging the systemic inflammatory response.
30. Is antibody treatment of circulating endotoxin a clinically important tool?
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Not yet. The neutralization of circulating endotoxin might give a theoretic benefit to patients with sepsis, and animal studies looked promising. But antigen/antibody complexes initiate complement cascade and release of activate leukocyte products such as leukotrienes that may further augment the inflammatory process. The complexes are also filtered in the kidney where they may further impair renal function. To date, no clinical therapeutic benefit has been demonstrated for such monoclonal antibody therapy.
31. What is the role of human recombinant activated protein C in patients with sepsis?
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Of the multiple clinical trials of mediator neutralization or receptor blockade, the evidence to date seems marginally favorable only for a few, and the major response to treatment comes from early and complete control of the focus of sepsis (not the cytokine sequelae).
References
WEB SITES
1. http://www.acssurgery.com/abstracts/acs/acs0102.htm
2. http://www.medscape.com
* Search: preoperative antibiotics
BIBLIOGRAPHY
1. Bartlett JG: Intra-abdominal sepsis. Med Clin North Am 79:599-617, 1995. Medline Similar articles
2. Bernard GR, Vincent JL, Laterre PF, et al: Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 344:699, 2001.
3. Bilik R, Burnweit C, Shandling B: Is abdominal cavity culture of any value in appendicitis? Am J Surg 175:267-270, 1998.
4. Christou NV, Turgeon P, Wassef R, et al: Management of intra-abdominal infections. The case for intraoperative cultures and comprehensive broad-spectrum antibiotic coverage. The Canadian Intra-abdominal Infection Study Group. Arch Surg 131:1193-1201, 1996. Medline Similar articles
5. Ciftci AO, Tanyei FC, Buyukpamukcu N, Hicsonmea A: Comparative trial of four antibiotic combinations for perforated appendicitis in children. Eur J Surg 163:591-596, 1997. Medline Similar articles
6. Falagas ME, Barefoot L, Griffith J, et al: Risk factors leading to clinical failure in the treatment of intra-abdominal or skin/soft tissue infections. Eur J Clin Microbiol Infect Dis 15:913-921, 1996. Medline Similar articles
7. Geelhoed GW: Preoperative skin preparation: Evaluation of efficacy, timing, convenience, and cost. Infect Surg 85:648-669, 1985.
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Abernathy’s Surgical Secrets, Updated Edition (Book w / Student Consult)
Author / s: Harken Alden H., Abernathy Charles, Moore Ernest Eugene
Year: 2004
Pages: 473
Publishers: Elsevier Mosby; 5th Bk & Acc edition
ISBN: 0323034160
