Organ-Specific Infections

Hepatic abscesses are rare, currently accounting for approximately

15 per 100,000 hospital admissions in the United States.
Pyogenic abscesses account for approximately 80% of cases,
the remaining 20% being equally divided among parasitic and
fungal forms.62 Formerly, pyogenic liver abscesses mainly were
caused by pylephlebitis due to neglected appendicitis or diverticulitis.
Today, manipulation of the biliary tract to treat a variety
of diseases has become a more common cause, although in
nearly 50% of patients no cause is identified. The most common
aerobic bacteria identified in recent series include E coli,
K pneumoniae, and other enteric bacilli, enterococci, and Pseudomonas
spp., while the most common anaerobic bacteria are
Bacteroides spp., anaerobic streptococci, and Fusobacterium
spp. Candida albicans and other related yeast cause the majority
of fungal hepatic abscesses. Small (<1 cm), multiple abscesses
should be sampled and treated with a 4 to 6 week course of
antibiotics. Larger abscesses invariably are amenable to percutaneous
drainage, with parameters for antibiotic therapy and
drain removal similar to those mentioned previously. Splenic
abscesses are extremely rare and are treated in a similar fashion.
Recurrent hepatic or splenic abscesses may require operative
intervention—unroofing and marsupialization or splenectomy,
respectively.
Secondary pancreatic infections (e.g., infected pancreatic
necrosis or pancreatic abscess) occur in approximately 10% to
15% of patients who develop severe pancreatitis with necrosis.
The surgical treatment of this disorder was pioneered by Bradley
and Allen, who noted significant improvements in outcome for
patients undergoing repeated pancreatic débridement of infected
pancreatic necrosis.63 Current care of patients with severe acute
pancreatitis includes staging with dynamic, contrast materialenhanced
helical CT scan to evaluate the extent of pancreatitis
(unless significant renal dysfunction exists in which case one
should forego the use of contrast material) coupled with the
use of one of several prognostic scoring systems. Patients who
exhibit clinical signs of instability (e.g., oliguria, hypoxemia,
large-volume fluid resuscitation) should be carefully monitored
in the ICU and undergo follow-up contrast enhanced CT examination
when renal function has stabilized to evaluate for development
of local pancreatic complications (Fig. 6-3). A recent
change in practice has been the elimination of the routine use
of prophylactic antibiotics for prevention of infected pancreatic
necrosis. Enteral feedings initiated early, using nasojejunal
feeding tubes placed past the ligament of Treitz, have been
associated with decreased development of infected pancreatic
151
CHAPTER 6 SURGICAL INFECTIONS
necrosis, possibly due to a decrease in gut translocation of bacteria.
These topics have been recently reviewed.64,65
The presence of secondary pancreatic infection should be
suspected in patients whose systemic inflammatory response
(fever, elevated WBC count, or organ dysfunction) fails to
resolve, or in those individuals who initially recuperate, only to
develop sepsis syndrome 2 to 3 weeks later. CT-guided aspiration
of fluid from the pancreatic bed for performance of Gram’s
stain and culture analysis can be useful. A positive Gram’s stain
or culture from CT-guided aspiration, or identification of gas
within the pancreas on CT scan, mandate surgical intervention.
The approach of open necrosectomy with repeated
debridements, although life saving, is associated with significant
morbidity and prolonged hospitalization. Efforts to
reduce the amount of surgical injury, while still preserving the
improved outcomes associated with debridement of the infected
sequestrum have led to a variety of less invasive approaches.66
These include endoscopic approaches, laparoscopic approaches
and other minimally invasive approaches. There are a limited
number of randomized trials reporting the use of these new techniques
currently. An important concept common to all of these
approaches, however, is the attempt to delay surgical intervention,
since a number of trials have identified increased mortality
when intervention occurs during the first two weeks of illness.
Data supporting the use of endoscopic approaches to this
problem include nearly a dozen case series and a randomized
trial.67,68 The reported mortality rate was 5%, with a 30% complication
rate. Most authors noted the common requirement
for multiple endoscopic debridements (similar to the open
approach), with a median of 4 endoscopic sessions required.
Fewer series report experience with the laparoscopic approach,
either transgastric or transperitoneal, entering the necrosis
through the transverse mesocolon or gastrocolic ligament. The
laparoscopic technique is carefully described in a recent publication.
69 Laparoscopic intervention is limited by the difficulty
in achieving multiple debridements and the technical
expertise required to achieve an adequate debridement. Mortality
in 65 patients in 9 case series reported was 6% overall.
Debridement of necrosis through a lumbar approach has
been advocated by a number of authors. This approach, developed
with experience in a large number of patients, 70 has been
recently subjected to a single center randomized prospective
Figure 6-3. Contrast-enhanced CT scan of pancreas 1ó weeks after
presentation showing large central peripancreatic fluid collection.
trial.71 This approach includes delay of intervention when possible
until 4 weeks after the onset of disease. Patients receive
transgastric or preferably retroperitoneal drainage of the sequestrum.
If patients do not improve over 72 hours, they are treated
with video-assisted retroperitoneal drainage (VARD), consisting
of dilation of the retroperitoneal drain tract, placement of
and irrigation, and debridement of the pancreatic bed (Fig. 6-4).
Repeat debridements are performed as clinically indicated,
with most patients requiring multiple debridements. In the
trial reported, patients randomized to VARD (n=43) compared
to those randomized to the standard open necrosectomy (n=45)
had a decreased incidence of the composite endpoint of complications
and death (40% vs. 69%), with comparable mortality rate,
hospital, and ICU lengths of stay. Patients randomized to VARD
had fewer incisional hernias, new-onset diabetes, and need for
pancreatic enzyme supplementation.
It is apparent that patients with infected pancreatic necrosis
can safely undergo procedures that are more minimal than
the gold-standard open necrosectomy with good outcomes.
However, to obtain good outcomes these approaches require an
experienced multidisciplinary team consisting of interventional
radiologists, gastroenterologists, surgeons, and others. Important
concepts for successful management include careful preoperative
planning, delay (if possible) to allow maturation of
the fluid collection, and the willingness to repeat procedures as
necessary till the majority if not all nonviable tissue has been
removed.
Infections of the Skin and Soft Tissue
These infections can be classified according to whether or not surgical
intervention is required. For example, superficial skin and
skin structure infections such as cellulitis, erysipelas, and lymphangitis
invariably are effectively treated with antibiotics alone,
although a search for a local underlying source of infection should
be undertaken. Generally, drugs that possess activity against the
causative gram-positive skin microflora are selected. Furuncles
or boils may drain spontaneously or require surgical incision and
drainage. Antibiotics are prescribed if significant cellulitis is present
or if cellulitis does not rapidly resolve after surgical drainage.
Community-acquired methicillin resistant Staphylococcus aureus
(MRSA) infection should be suspected if infection persists after
treatment with adequate drainage and administration of first line
antibiotics. These infections may require more aggressive drainage
and altered antimicrobial therapy.72
Aggressive soft tissue infections are rare, difficult to diagnose,
and require immediate surgical intervention plus administration
of antimicrobial agents. Failure to do so results in an
extremely high mortality rate (~80%–100%), and even with
rapid recognition and intervention, current mortality rates are
high (16%–24%).73 Eponyms and classification in the past have
been a hodgepodge of terminology, such as Meleney’s synergist
gangrene, rapidly spreading cellulitis, gas gangrene, and
necrotizing fasciitis, among others. Today it seems best to delineate
these serious infections based on the soft tissue layer(s)
of involvement (e.g., skin and superficial soft tissue, deep soft
tissue, and muscle) and the pathogen(s) that cause them.
Patients at risk for these types of infections include those
who are elderly, immunosuppressed, or diabetic; those who
suffer from peripheral vascular disease; or those with a combination
of these factors. The common thread among these host
factors appears to be compromise of the fascial blood supply
to some degree, and if this is coupled with the introduction of
6
152
PART I BASIC CONSIDERATIONS
B
C
Figure 6-4. Infected pancreatic necrosis. (A) Open necrosectomy
specimen with pancreatic stent in situ. It is important to gently
debride only necrotic pancreatic tissue, relying on repeated operation
to ensure complete removal. (B) For video-assisted retroperitoneal
debridement (VARD), retroperitoneal access is gained through
radiologic placement of a drain, followed by dilation 2-3 days later.
(C) Retroperitoneal cavity seen through endoscope during VARD.
exogenous microbes, the result can be devastating. However, it
is of note that over the last decade, extremely aggressive necrotizing
soft tissue infections among healthy individuals due to
streptococci have been described as well.
Initially, the diagnosis is established solely upon a constellation
of clinical findings, not all of which are present in every
patient. Not surprisingly, patients often develop sepsis syndrome
or septic shock without an obvious cause. The extremities,
perineum, trunk, and torso are most commonly affected, in that
order. Careful examination should be undertaken for an entry site
such as a small break or sinus in the skin from which grayish,
turbid semipurulent material (“dishwater pus”) can be expressed,
as well as for the presence of skin changes (bronze hue or brawny
induration), blebs, or crepitus. The patient often develops pain
at the site of infection that appears to be out of proportion to
any of the physical manifestations. Any of these findings mandates
immediate surgical intervention, which should consist of
exposure and direct visualization of potentially infected tissue
(including deep soft tissue, fascia, and underlying muscle) and
radical resection of affected areas. Radiologic studies should not
be undertaken in patients in whom the diagnosis seriously is considered,
as they delay surgical intervention and frequently provide
confusing information. Unfortunately, surgical extirpation
of infected tissue frequently entails amputation and/or disfiguring
procedures; however, incomplete procedures are associated
with higher rates of morbidity and mortality (Fig. 6-5).
During the procedure a Gram’s stain should be performed
on tissue fluid. Antimicrobial agents directed against Grampositive
and Gram-negative aerobes and anaerobes (e.g., vancomycin
plus a carbapenem), as well as high-dose aqueous penicillin
G (16,000,000 to 20,000,000 U/d), the latter to treat clostridial
pathogens, should be administered. Approximately 50% of such
infections are polymicrobial, the remainder being caused by a single
organism such as Streptococcus pyogenes, Pseudomonas aeruginosa,
or Clostridium perfringens. The microbiology of these
polymicrobial infections is similar to that of secondary microbial
peritonitis, with the exception that Gram-positive cocci are more
commonly encountered. Most patients should be returned to the
operating room on a scheduled basis to determine if disease progression
has occurred. If so, additional resection of infected tissue
and debridement should take place. Antibiotic therapy can be
refined based on culture and sensitivity results, particularly in the
case of monomicrobial soft tissue infections. Hyperbaric oxygen
therapy may be of use in patients with infection caused by gasforming
organisms (e.g., Clostridium perfringens), although the
evidence to support efficacy is limited to underpowered studies
and case reports.In the absence of such infection, hyperbaric oxygen
therapy has not shown to be effective. 74