Healthcare-Associated Infections _ ______________________________________________________________
Attention should also be directed at strategies to prevent surgi- cal site infections with MRSA. The use of an MRSA prevention bundle—adherence to the guidelines for hand hygiene, decon- tamination of environment and equipment, active surveillance cultures, and contact precautions for patients with MRSA infection or colonization—led to significant decreases in the overall rate of surgical site infections in one study, with a 1% decrease in surgical site infections after cardiac surgery and a 65% decrease after orthopedic surgeries [180]. Diagnosis IDSA guidelines on the diagnosis and management of skin and soft tissue infections include a section on surgical site infections [168; 181]. The guidelines note that the most reli- able diagnostic information is the physical appearance of the site; local signs of infection include pain, swelling, erythema, and purulent drainage [168; 181]. Clinical manifestations of a surgical site infection do not occur for at least 5 days postoperatively, with many infections not becoming apparent for as long as 2 weeks [168; 181]. The IDSA notes that most postoperative fevers are not associated with a surgical site infection [168; 181]. Surgical site infections are classified as superficial incisional, deep incisional, and organ/space infections. Strict criteria and standardized definitions are used in reporting infections and in surveillance programs [31; 176]. The CDC described the criteria for each type of infection in its guidelines for the pre- vention of surgical site infections and defined the infections in the NHSN system according to this classification [31; 129; 182]. Superficial Incisional Classification Infection occurs within 30 days after the operative procedure and involves only skin and subcutaneous tissue of the incision and at least one of the following : • Purulent draining from the superficial incision • Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision • At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat, and superficial incision is deliberately opened by surgeon, unless incision is culture-negative • Diagnosis of superficial incisional surgical site infection by the surgeon or attending physician Deep Incisional Classification Infection occurs within 30 or 90 days after the operative pro- cedure if no implant is left in place or within 1 year if implant is in place and the infection appears to be related to the opera- tive procedure and involves deep soft tissues (e.g., fascial and muscle layers) of the incision and at least one of the following : • Purulent drainage from the deep incision but not from the organ/space component of the surgical site
• Deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever (>38 degrees Centigrade) or localized pain or tenderness, unless incision is culture-negative • Abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiographic examination • Diagnosis of a deep incisional surgical site infection by a surgeon or attending physician Organ/Space Classification Infection occurs within 30 or 90 days after the operative procedure if no implant is left in place or within 1 year if the implant is in place and the infection appears to be related to the operative procedure and infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure and at least one of the following: • Purulent drainage from a drain that is placed through a stab wound into the organ/space • Organisms isolated from an aseptically obtained culture or fluid or tissue in the organ/space • Abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiographic examination • Diagnosis of an organ/space surgical site infection by a surgeon or attending physician Treatment Based on expert opinion, the IDSA recommends opening an infected surgical site, removing the infected material, and con- tinuing dressing changes until the wound heals by secondary intention [168]. Although treatment with antibiotics is com- monly started when a surgical site infection is diagnosed, the IDSA notes that little evidence has supported this approach [168]. A short course (24 to 48 hours) of antibiotics may be indicated for patients with a temperature higher than 38.5 degrees Centigrade or a pulse rate of more than 100 beats/min [168]. The guidelines add that treatment is usually empirical but may be selected according to results of wound culture [168]. IDSA offers guidance on the selection of antibiotics according to the operative site [168]. Intestinal or Genital Tract Single agents: ticarcillin/clavulanate, piperacillin/tazobactam, imipenem/cilastatin, meropenem, ertapenem Combination agents: ceftriaxone/metronidazole, ciprofloxa- cin/metronidazole, levofloxacin/metronidazole, ampicillin- sulbactam/gentamicin ampicillin-sulbactam/tobramycin
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