MICROBIOLOGY FOR SURGICAL INFECTIONS MICROBIOLOGY FOR SURGICAL INFECTIONS DIAGNOSIS, PROGNOSIS AND TREATMENT Edited by Kateryna Kon MD, PhD KharkivNationalMedicalUniversity,Kharkiv,Ukraine Mahendra Rai MSc, PhD SantGadgeBabaAmravatiUniversity,Amravati,Maharashtra,India DepartmentofChemicalBiology,InstituteofChemistry,UniversityofCampinas,CampinasSP,Brazil AMSTERDAM(cid:129)BOSTON(cid:129)HEIDELBERG(cid:129)LONDON NEWYORK(cid:129)OXFORD(cid:129)PARIS(cid:129)SANDIEGO SANFRANCISCO(cid:129)SINGAPORE(cid:129)SYDNEY(cid:129)TOKYO AcademicPressisanimprintofElsevier AcademicPressisanimprintofElsevier 32JamestownRoad,LondonNW17BY,UK 225WymanStreet,Waltham,MA02451,USA 525BStreet,Suite1800,SanDiego,CA92101-4495,USA Copyrightr2014ElsevierInc.Allrightsreserved. Nopartofthispublicationmaybereproduced,storedinaretrievalsystemortransmittedin anyformorbyanymeanselectronic,mechanical,photocopying,recordingorotherwisewithout thepriorwrittenpermissionofthepublisher.Permissionsmaybesoughtdirectlyfrom Elsevier’sScience&TechnologyRightsDepartmentinOxford,UK:phone(144)(0)1865843830; fax(144)(0)1865853333;email:[email protected],visittheScienceand TechnologyBookswebsiteatwww.elsevierdirect.com/rightsforfurtherinformation. Notice Noresponsibilityisassumedbythepublisherforanyinjuryand/ordamagetopersonsor propertyasamatterofproductsliability,negligenceorotherwise,orfromanyuseoroperation ofanymethods,products,instructionsorideascontainedinthematerialherein.Becauseofrapid advancesinthemedicalsciences,inparticular,independentverificationofdiagnosesand drugdosagesshouldbemade. BritishLibraryCataloguing-in-PublicationData AcataloguerecordforthisbookisavailablefromtheBritishLibrary LibraryofCongressCataloging-in-PublicationData AcatalogrecordforthisbookisavailablefromtheLibraryofCongress ISBN:978-0-12-411629-0 ForinformationonallAcademicPresspublications visitourwebsiteatelsevierdirect.com PrintedandboundinUnitedStatesofAmerica 14 15 16 17 18 10 9 8 7 6 5 4 3 2 1 Preface Surgical infections represent a diverse group of diseases, which despite advances in techniques of surgery and anesthesia, the presence of modern equipment and improving perioperative health care in hospitals, still lead to significant morbidity and mortality. The rapid increase in levels of antibiotic resistance and the appearance of new multidrug- resistant pathogensmakes it necessary toconstantly updaterecommendations onthe man- agement of infections, and the present book reviews the most recent guidelines on the prevention, diagnosis and treatment of surgical infections of different locations, with par- ticular emphasis on intra-abdominal, cardiovascularand skin andsofttissue infections. The scope of the chapters encompasses reviews of in vitro studies of the principles of prevention of surgical infections, such as the evaluation of bacterial adherence to surgical materials, as well as clinical studies on the management of a broad spectrum of surgical infections, including anastomotic leakage after colorectal surgery, infectious complications of dialysis access, infective endocarditis, necrotizing soft tissue infections, diabetic foot infections and others. In addition, alternative methods of antimicrobial treatment of surgi- cal infections are also discussed in several chapters, such as in vitro and in vivo studies on wound healing and anti-infectious properties of plant extracts, essential oils, and zoothera- peutics methods. Although the most common cause of surgical infections is bacteria, the role of other microorganisms should not be disregarded. In consideration of this fact, one chapter is also devoted to understanding diagnostic approaches for invasive mycoses in surgical patients,as this pathologyhas attracted much attention in recent years. Selection of the optimal treatment strategy is impossible without predicting a probable outcomeoftheinfectionbasedonapatient’slaboratoryandclinicalparameters.Nowadays, there are a large number of studies dedicated to the development of scoring systems using modern statistical methods for assessment of the severity of a patient’s state and for pre- dicting the course and outcome in different surgical infections. Some such scoring systems have gained great popularity in the medical community, such as APACHE II (Acute Physiology and Chronic Health Evaluation II) system, SAPS (Simplified Acute Physiology Score),MPI(MannheimPeritonitisIndex),etc.,andthisbookalsosummarizesstudiesofthe efficacy of these and other scoring systems in the prognosis of surgical infections, particu- larlyinsecondaryperitonitis. The book explores current trends in the etiology and antibiotic resistance of pathogens causing different types of surgical infections; it discusses recent advances in diagnostic approaches in bacterial and non-bacterial surgical infections; it reviews methods of prog- nosis of the course and outcome of surgical infections; and it also summarizes recent ix x PREFACE guidelines for prophylaxis of infectious complications in surgery, and for improvement of diagnosis andtreatment of surgical infections. The book will beveryuseful to microbiologists,surgeons, infectiousdiseasesspecialists, researchers in surgery, clinical microbiologists, pharmacologists, and those who are inter- ested in tacklingthe problem of antibioticresistance. The editors would like to thank Elizabeth Gibson, Editorial Project Manager, Academic Press/Elsevier S&T Books, Waltham, MA, USA for her help and valuable suggestions, the contributors for devoting their time and efforts to this book, and the reviewers for their comments for improving the chapters. Prof. Rai thankfully acknowledges FAPESP, Brazil for providing financial support to visit the Institute of Chemistry, Biological Chemistry Laboratory, Universidade Estadual de Campinas, Campinas, SP, Brazil. Kateryna Kon Mahendra Rai List of Contributors Ali Alizzi Cardiothoracic Surgical Unit, Elena Eraso Departamento de Inmunolog´ıa, AshfordHospital,Adelaide,Australia. Microbiolog´ıa y Parasitolog´ıa, Universidad Luca Ansaloni General Surgery Department, del Pa´ıs Vasco/Euskal Herriko Unibertsitatea (UPV/EHU),Bilbao,Spain. PapaGiovanniXXIIIHospital,Bergamo,Italy. VenkateshKumarAriyamuthu Departmentof Jaime Esteban Department of Clinical Medicine, University of Missouri Columbia, Microbiology, IIS-Fundacio´n Jime´nez D´ıaz, Missouri. Madrid,Spain. Ramkrishna Bhalchandra Tata Medical Leticia M. Estevinho CIMO-Mountain Center,Kolkata,India. Research Center, Department of Biology and Biotechnology, Agricultural College of Sanjay Bhattacharya Tata Medical Center, Braganc¸a, Polytechnic Institute of Braganc¸a, Kolkata,India. Braganc¸a,Portugal. Rodolfo Leonel Bracho-Riquelme Instituto de Guillermo Ezpeleta Departamento de Investigacio´n Cient´ıfica de la Universidad Medicina Preventiva y Salud Pu´blica, Jua´rez del Estado de Durango, Durango, Facultad de Medicina y Odontolog´ıa, Me´xico. Universidad del Pa´ıs Vasco/Euskal Michela Giulii Capponi General Surgery Herriko Unibertsitatea (UPV/EHU), Bilbao, Department, Papa Giovanni XXIII Hospital, Spain. Bergamo,Italy. Xesus Fea´s Department of Organic Chemistry, Kunal Chaudhary Department of Medicine, Faculty ofSciences, University ofSantiago de UniversityofMissouriColumbia,Missouri. Compostela,Lugo,Spain. Yi-Feng Chen Institute of Biotechnology, Donald E. Fry Department of Surgery, Jiangsu Academy of Agricultural Sciences, Northwestern University Feinberg School of Nanjing,Jiangsu,China. Medicine, Chicago, Illinois, and the Andreas K. Demetriades Department of Department of Surgery, University of New Neurosurgery, Western General Hospital, Mexico School of Medicine, Albuquerque, Edinburgh,UK. NewMexico. Daliparthy Devi Pratyush Department of Vikas Gautam Department of Medical Endocrinology and Metabolism, Institute of Microbiology, Postgraduate Institute of Medical Sciences, Banaras Hindu University, Medical Education and Research, Varanasi,India. Chandigarh,India. Lu´ısG.Dias CIMO-MountainResearchCenter, Gaurav Goel Tata Medical Center, Kolkata, Department of Biology and Biotechnology, India. Agricultural College of Braganc¸a, Polytechnic Enrique Go´mez-Barrena Department of InstituteofBraganc¸a,Braganc¸a,Portugal. Orthopedics, IdiPAZ-Hospital Universitario Teresa Dias CIMO-Mountain Research Center, LaPaz,Madrid,Spain. Department of Biology and Biotechnology, KarolinGraf InstituteforMedicalMicrobiology Agricultural College of Braganc¸a, Polytechnic and Hospital Epidemiology, Hannover InstituteofBraganc¸a,Braganc¸a,Portugal. MedicalSchool,Hannover,Germany. xi xii LISTOFCONTRIBUTORS Sanjeev Kumar Gupta Department of General Guillermo Quindo´s Departamento de Surgery, Institute of Medical Sciences, Inmunolog´ıa, Microbiolog´ıa y Parasitolog´ıa, BanarasHinduUniversity,Varanasi,India. Universidad del Pa´ıs Vasco/Euskal TorstenHerzog DepartmentofSurgery,St.Josef Herriko Unibertsitatea (UPV/EHU), Bilbao, Spain. Hospital,Ruhr-UniversityBochum,Germany. Lalawmpuia Hmar Tata Medical Center, Mahendra Rai Department of Biotechnology, Kolkata,India. Sant Gadge Baba Amravati University, Amravati,Maharashtra,India. Kateryna Kon Department of Microbiology, Hariharan Regunath Department of Medicine, Virology and Immunology, Kharkiv National UniversityofMissouriColumbia,Missouri. MedicalUniversity,Kharkiv,Ukraine. Surya Kumar Singh Department of Florian Ringel Department of Neurosurgery, Endocrinology and Metabolism, Institute of Klinikum rechts der Isar, Technische Medical Sciences, Banaras Hindu University, Universita¨tMu¨nchen,Mu¨nchen,Germany. Varanasi,India. FerranSanchez-Reus ServiciodeMicrobiolog´ıa, Ali Parsaeimehr G. S. Davtyan Institute of HospitaldelaSantaCreuiSantPau,Barcelona, HydroponicsProblems,NationalAcademyof Spain. Sciences,Yerevan,RepublicofArmenia. Elmira Sargsyan G. S. Davtyan Institute of Ananias Pascoal CIMO-Mountain Research HydroponicsProblems,NationalAcademyof Sciences,Yerevan,RepublicofArmenia. Center, Department of Biology and Biotechnology, Agricultural College of Sarah Shepard SA Pathology, Adelaide, Braganc¸a, Polytechnic Institute of Braganc¸a, Australia. Braganc¸a,Portugal. Lipika Singhal Department of Medical Javier Pema´n Servicio de Microbiolog´ıa, Microbiology,PostgraduateInstituteofMedical HospitalUniversitarioLaFe,Valencia,Spain. EducationandResearch,Chandigarh,India. Concepcio´n Pe´rez-orge-eremarch Department John-Paul Tantiongco Cardiothoracic Surgical ofClinicalMicrobiology,IIS-Fundacio´nJime´nez Unit, Flinders Medical Center, Adelaide, D´ıaz,Madrid,Spain. Australia. Ramo´n Pe´rez-Tanoira Department of Clinical Shalbha Tiwari Department of Endocrinology Microbiology, IIS-Fundacio´n Jime´nez D´ıaz, and Metabolism, Institute of Medical Madrid,Spain. Sciences, Banaras Hindu University, Michele Pisano General Surgery Department, Varanasi,India. PapaGiovanniXXIIIHospital,Bergamo,Italy. Waldemar Uhl Department of Surgery, St. Elia Poiasina General Surgery Department, Josef Hospital, Ruhr-University Bochum, PapaGiovanniXXIIIHospital,Bergamo,Italy. Germany. Amber Prasad Department of Medical Ralf-Peter Vonberg Institute for Medical Microbiology,PostgraduateInstituteofMedical Microbiology and Hospital Epidemiology, EducationandResearch,Chandigarh,India. HannoverMedicalSchool,Hannover,Germany. C H A P T E R 1 Infection Control Measures for the Prevention of Surgical Site Infections Karolin Graf and Ralf-Peter Vonberg Institutefor Medical Microbiology and Hospital Epidemiology, Hannover Medical School,Hannover,Germany CONSEQUENCES OF SURGICAL SITE INFECTIONS It is as simple as this: The best you can do about surgical site infections (SSI) is not to let them happen in the first place. Today the occurrence of SSI represents one of the most severe complications in all types of surgical procedures, and it will have an enormous impact on the ongoing course of recovery of the affected patient. It leads to significantly increased morbidity and mortality of patients in various medical disciplines.1(cid:1)3 Besides their importance with respectto suchclinicalconsequences,SSI should also concern hospi- tals and health care systems for economic reasons.4,5 Depending upon the type of surgery, the prolonged length of stay (LOS) in the hospital may vary from 3 to 21 days.1 According to a review of the literature on SSI in general6 and to a recently published large estimation onSSIinorthopedics(412,356totalhipand784,335totalkneearthroplasties)inparticular,7 SSI will roughly double the magnitude of the cost for a case patient. Based on the 2005 Healthcare Cost and Utilization Project National Inpatient Sample (HCUP NIS), which included 723,490 surgical patients with 6,891 SSI, the average LOS was 9.7 days and costs increased by $20,842 per admission. This leads to nearly 1,000,000 additional inpatient- days and $1,600,000,000 excess costs for the US alone.8 Evidence-based infection control guidelines for the prevention of SSI have been pub- lished, for example by the Hospital Infection Control Practices Advisory Committee (HICPAC) from the Centers for Disease Control and Prevention (CDC)9 and by the Society for Healthcare Epidemiology of America (SHEA) in collaboration with the Infectious Diseases Society of America (IDSA) (Table 1.1).10 This chapter provides an overview of patient-derived (endogenous) risk factors for SSI development, and summarizes the most MicrobiologyforSurgicalInfections DOI:http://dx.doi.org/10.1016/B978-0-12-411629-0.00001-5 3 ©2014ElsevierInc.Allrightsreserved. 4 1. INFECTIONCONTROLMEASURESFORTHEPREVENTIONOFSURGICALSITEINFECTIONS TABLE1.1 SummaryofEvidence-basedRecommendationsoftheSocietyforHealthcareEpidemiologyof America(SHEA)forSSIPrevention Recommendation Grade Useevidence-basedstandardswhenimplementingpreventionmeasures. A-II Controlserumbloodglucoselevels;reduceglycosylatedhemoglobinA1clevelsto,7%beforesurgery, A-II ifpossible. Increasedosingofprophylacticantimicrobialagentformorbidlyobesepatients. A-II Encouragesmokingcessationwithin30daysbeforeprocedure. A-II Noformalrecommendationwithrespecttoimmunosuppressivemedications;avoidtheminthe C-II perioperativeperiod,ifpossible. Donotroutinelydelaysurgerytoprovideparenteralnutrition. A-I Donotremoveunlesshairwillinterferewiththeoperation;ifremovalisnecessary,removeby A-II clippinganddonotuserazors. Identifyandtreatinfectionsremotetothesurgicalsitebeforeelectivesurgery. A-II Washandcleanskinaroundincisionsite;useanappropriateantisepticagent. A-II Useappropriateantisepticagent(e.g.,analcohol-basedsurgicalhandantisepsisproduct)fora A-II 2(cid:1)5minutepreoperativesurgicalscrub. Administerantimicrobialprophylaxisonlywhenindicatedinaccordancewithevidence-based A-I standardsandguidelines. Administerantimicrobialprophylaxiswithin1hourbeforeincisiontomaximizetissueconcentration. A-I Selectappropriateagentsonthebasisofsurgicalprocedure,mostcommonpathogens,andpublished A-I recommendations. Donotroutinelyusevancomycinforantimicrobialprophylaxis. B-II Stopprophylaxiswithin24hoursaftertheprocedureforallproceduresexceptcardiacsurgery A-I (stopwithin48hourshere). Handletissuecarefullyanderadicatedeadspace. A-III Controlbloodglucoselevelduringtheimmediatepostoperativeperiodforpatientsundergoing A-I cardiacsurgery. Adheretostandardprinciplesofoperatingroomasepsis. A-III Noformalrecommendationwithrespecttooperativetime;minimizeasmuchaspossible. A-III Adheretoventilation,followAmericanInstituteofArchitects’recommendationsforventilation. C-I Minimizeoperatingroomtraffic. B-II Useanapprovedhospitaldisinfectanttocleansurfacesandequipment. B-III Sterilizeallsurgicalequipmentaccordingtopublishedguidelines;minimizetheuseofflash B-I sterilization. PerformsurveillanceforSSI. A-II (Continued) I. INFECTIONCONTROLMEASURESFORTHEPREVENTIONOFSURGICALINFECTIONS 5 INFECTIONCONTROLMEASURESBEFORETHESTARTOFTHESURGICALPROCEDURE TABLE1.1 (Continued) Recommendation Grade ProvideongoingfeedbackonSSIsurveillanceandprocessmeasurestosurgicalandperioperative A-II personnelandleadership. PerformexpandedSSIsurveillancetodeterminethesourceandextentoftheproblemandtoidentify B-II possibletargetsforintervention. MeasureandprovidefeedbackofSSIrates,antimicrobialprophylaxis,properhairremoval,and A-III glucosecontrol(forcardiacsurgery) Increasetheefficiencyofsurveillancethroughtheuseofautomateddata. A-II EducatesurgeonsandperioperativepersonnelaboutSSIprevention. A-III EducatepatientsandtheirfamiliesaboutSSIprevention,asappropriate. A-III important infection control measures according to the time point of their implementation (before, duringor after the operation on thepatient). INFECTION CONTROL MEASURES BEFORE THE START OF THE SURGICAL PROCEDURE Patient-Derived (Endogenous) Risk Factors for Surgical Site Infections Diseases. Some patients present with certain characteristics that will increase their risk of subsequent SSI acquisition. Unfortunately, a number of those endogenous risk facts cannot be influenced by proper infection control measures. This includes (but does not exclusively applyto)underlyingdiseaseswhichincreasetheoverallcomorbiditiyburdensuchascancer, cirrhosis and other liver diseases, congestive heart failure, coagulopathies, and chronic obstructive lung diseases,7,11,12 patients with any kind of severe immune-suppression,13 infantsaged lessthan1year,14,15olderpatientsagedmorethan65years,16ahigherscoreon the American Society of Anaesthesiology (ASA) classification,16,17 and patients with a need forsurgicalproceduresinmicrobiologicallycontaminatedareasasexpressedbytheprimary wound contamination class.18(cid:1)20 Whenever staff recognizes one or more of the above men- tionedriskfactors,anincreasedawarenessofpotentialSSIisnecessary.Inaddition,thereare severalpatient-derivedriskfactorsthatcan,infact,bepositivelyinfluencedinprinciple.This mayoftenbedifficult,butisstillworthwhileintermsofthepatient’soutcome.Thesemodifi- ablecharacteristicswillbediscussedinmoredetailinthefollowingsections. Overweight. Overweight patients with an increased body mass index (BMI) show high- erSSI rates thando patientswith anormal body weight.13,17,21,22 In arandomized prospec- tive study in a group of 1,032 patients, Beldi et al.23 showed that a BMI . 30kg/m2 doubledtheriskofanSSI.Tranetal.checkedforSSIriskfactors in969womenaftercesar- ean section: every five-unit increment in the BMI increased the odds ratio (OR) for an SSI by a factor of two.24 Yeung et al. recruited a consecutive cohort of 210 patients from vari- cose vein surgery. Nine of 53 patients (17.0%) with a BMI $ 30kg/m2 suffered from an I. INFECTIONCONTROLMEASURESFORTHEPREVENTIONOFSURGICALINFECTIONS