Overall, surgical site infections (SSIs) are the leading reason for nosocomial infections, comprising 38% of these complications. By definition, to be an SSI, an infection must occur within 30 days after plastic surgery. SSIs could be broken down into three general categories. Superficial incisional SSIs involve only the skin or subcutaneous tissue of the incision. Signs and symptoms of the type of infection may include pain, swelling, redness, warmth and tenderness.
Deep incisional SSIs demonstrate either purulent drainage from deeper tissue, a deep incisional dehiscence, or an abscess in the depth from the incision. Lastly, organ or deep space SSIs involve infections in manipulated regions apart from your skin and subcutaneous tissue that was opened throughout the procedure. By definition, these infections must contain purulent drainage, positive cultures with fluid aspiration or documentation of the presence of the abscess. If a foreign body for example mesh or titanium was left in the wound an SSI can occur as much as one year postoperatively.
Generally speaking, the overall well being and also the harshness of any comorbid conditions determine how susceptible a patient would be to wound infections. The American Society of Anesthesiology rates patients' operative risk according to their degree of illness and comorbidities, termed the ASA class. There is a close correlation between your harshness of the preoperative risk and the risk of wound infection. Furthermore, greater operative time is also related to an increased risk of developing an SSI.
When planning a surgical procedure, the surgeon must think about the degree of expected contamination. Clean surgical treatments are the ones that involve only skin and also the musculoskeletal soft tissue and carry approximately a 2% chance of developing an SSI. Clean-contaminated procedures are those that involve the planned opening of a hollow viscus this will let you 7-15% risk of becoming infected.
Contaminated procedures are the ones that introduce nonsterile, bacteria-rich contents into the wound for a short period of your time and lead to SSIs in 20% of cases. Dirty procedures take place in an infected setting. Approximately 20-40% of these wounds will become infected if closed primarily.
Whereas most SSI are caused by skin derived Gram-positive cocci, including Staphylococcus aureus, coagulase-negative staphylococci such as Staphylococcus epidermidis and Enterococcus species, site-specific pathogens, may infect wounds.
Consideration for Gram-negative bacilli should be given to any wound that is located near the site of bowel injury or repair, and when either bowel or tracheopharyngeal structures are violated, both enteric aerobic bacteria for example Escherichia coli and anaerobic bacteria such as Bacteroides fragilis may be of interest.
Prophylaxis for clean surgery is controversial. It's generally accepted that when bone is violated or when a prosthesis is inserted, preoperative antibiotics are indicated. Less convincing data exists for straightforward soft tissue surgery. When selecting an antibiotic agent, the next factors should be considered:
Long prophylactic courses happen to be associated with an increased risk of nosocomial infections and multi-drug resistance. For neat and most clean-contaminated cases, a first-generation cephalosporin should be used. If your patient has a documented penicillin allergy, clindamycin is an alternative. Only in the setting of the hospitalized patient in an institution that carries a high rate of methicillin-resistant S. aureus (MRSA), should vancomycin be considered for prophylaxis.
It is important to recall that the timing of the antibiotic dose determines its effectiveness. Preoperative prophylaxis should be closed within 2 hours of incision time. Given too soon, the antibiotic can be cleared before the case is started. Some benefit can be gained from intraoperative dosing if antibiotics aren't given before the situation begins, but no benefit has been confirmed when the first dose is offered following the case ends.
This loss of benefit after skin closure is related to the fact that sutured wounds exist in a low blood flow state because of vasoconstriction, using electrocauterization for hemostasis, and the constrictive effects of the suture closure. Therefore, antibiotics won't get to the surgical site. In extremely lengthy cases, redosing intraoperatively is recommended.
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