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88 Cards in this Set

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What is the definition of contamination?
The INTRODUCTION of organisms into a wound
How common is contamination? Infection?
Contamination Happens all the time, but infection is prevented more often
What is the definition of infection?
The ESTABLISHMENT of organisms in a wound and subsequent host reaction
What is the definition of bacteremia?
The presence of bacteria in the blood
What is the definition of sepsis/ septicemia?
The presence of sufficient bacteria in the blood causing illness
*Needs host immune response
What is the definition of endotoxemia?
The presence of endotoxins in blood and resulting illness
What is the definition of a surgical site infection?
Infection of incision, tissues surrounding the incision, adjacent organ or viscous
How is a complication different from a surgical site infection?
Complications are distant infections
What are the 3 classifications of surgical site infections?
1) Superficial incisional SSI
2) Deep incisional SSI
3) Organ or space SSI
What is the rate of occurrence of surgical site infections in SA surgery? LA surgery?
SA: 5.5%
LA: 7% in LA elective abdominal surgery
What are 3 ways that surgical site infection affects the outcome of surgery?
1) Increased postoperative morbidity/ mortality
2) Increased cost of therapy
3) Prolonged hospitalization
What are 6 ways of reducing the incidence of surgical site infection?
1) High standards of aseptic technique
2) Appropriate/ judicious use of antibiotics
3) Appropriate preoperative planning
4) Good case selection
5) Excellent surgical technique
6) Proper postoperative care
What are 5 host factors that increase the risk of post-op infections?
1) Decreased immune competence
2) Prior irradiation of the surgical site
3) Older age of the animals (SA > 8 years)
4) Distant sites of active infection
e.g. purulent drainage from a wound distant from surgical site
5) Abnormal body condition scores
When should surgery sites be clipped, before or after anesthetic induction? Why?
Surgery sites are clipped after induction, if clipped before anesthetic induction then animals are 3X more likely to develop infection
-superficial skin infections from clipper abrasions and cuts
What are 3 factors before surgery (other than time of clipping) that can affect the chances of developing surgical site infection?
1) Inadequate skin preparation of the surgical site
2) Duration of anesthesia >60 minutes
3) Administration of propofol as part of anesthetic protocol
How does using propofol as an anesthetic affect the chances of developing postop wound infections in a clean procedure?
Using Propofol animals are 3.8x more likely to develop post-op infection
Why can propofol increase the chances of infection?
It's a lipid-based emulsion that supports rapid microbial growth secondary to external contamination
-Administration of contaminated solution causes temporary bacteremia
What is the critical level of contamination that results in surgical site infection?
>10^5 organisms/gram of tissue
-influenced by pathogenicity and virulence
-Fewer needed if foreign body present
A surgery > ______ minutes puts the patient at an increased risk of surgical site infection.
> 90 minutes
-exact mechanism unclear:
recolonization of prepped area
more tissue damage
greater depression of host defenses
What type of suture material puts the patient at an increased risk of surgical site infection?
Braided/multifilament suture material
-Bacteria can hide in the interstices of the suture--> biofilm production
-1 braided silk suture reduces the number of S. aureus organisms required to 10^2
Why does the presence of any foreign material (implants!) prolong healing?
Prolongs inflammatory phase of wound healing
-Inhibit normal defense mechanisms
What are 5 factors during surgery that can cause inhibition of normal host defenses?
1) Blood clots
-Bacteria love to live in blood
2) Ischemic tissue
-anaerobes
3) Charred tissue
-Use electrosurgery sparingly
4) Fluid pockets
5) Foreign material
What are 3 ways to decrease contamination prior to surgery?
1) Wear gloves
2) Cover open wounds w/ sterile dressings while you stabilize the animal
3) Clean equipment and instrumentation regularly
What are 8 ways to decrease contamination in surgery?
1) Copious saline lavage
2) Debride wounds
3) Anatomical tissue apposition
4) Use surgical drains where needed
5) Proper suture selection
6) Closure of dead space
7) Judicious hemostasis
-discriminate use of electrocautery
8) Gentle tissue handling
-HALSTED'S PRINCIPLES
What is the definition of antimicrobial prophylaxis (W/ regards to surgery)?
Administration of antimicrobial agent prior to surgical incision
-Beta lactams: penicllin, cephalosporins
The recommendations for administration of antimicrobial prophylaxis is based up the ________ system.
National research Council Wound Classification System
How does the National Research Council Wound Classification system categorize wounds?
Based on the extent of operative contamination
-Antibiotic prophylaxis according to classification
What is the main criticism of the National Research Wound Classification system?
Too broad
No risk stratification within groups (confounding risk factors identified)
The wound classification system has poor association with SSI and what equine surgery?
Poor association w/ Equine abdominal sx
-Better association w/ SSI in equine orthopedic sx
What is a "clean" wound according to the wound classification system?
Non-traumatic surgical wound
No breaks in aseptic technique
e.g. castration, OVH- only trauma tissue experiences is you cutting into it and handling it
What is a "clean-contaminated" wound according to the wound classification system?
Sx on respiratory, GI, U/G tracts w/o major spillage
Minor break in aseptic technique e.g. spay where touch something non-sterile and have to change gloves= minor break in aseptic technique
What is a "contaminated" wound according to the wound classification system?
Gross spillage from viscous organ
Open wound <6 hours old
Major break in aseptic technique
What is a "dirty" wound according to the wound classification system?
Abscess, infected tissues encountered
Open wound > 6 hours old
What are 2 controversies recording the use of antimicrobials for clean surgery?
Technically not warranted
Increased infection rate w/ antibiotic therapy longer than 24 h peri-op!!!
Antimicrobial prophylaxis is only recommended for what type of surgeries?
Clean contaminated and selected contaminated surgeries
-lacerations < 6 h old
What type of antimicrobial use should be used for contaminated/ dirty surgeries?
Antimicrobial therapy
When is antimicrobial prophylaxis used for clean procedures?
When the infection would be catastrophic to the outcome of the procedures
-Total hip replacement
-Pacemaker
-Any surgery > 90 minutes
Do you use antimicrobial prophylaxis for implants?
Yes, they act as foreign bodies, also have to continue antibiotics
What are 2 concentration dependent drugs used for antimicrobial prophylaxis? What does this mean?
Aminoglycosides
fluoroquinolones
-Successful therapy depends on the peak concentration above the MiC achieved during therapy
What are time dependent drugs? What's an example?
Successful therapy depends on the time spent above MiC during therapy
The choice of antimicrobial for perioperative prophylaxis has to do with what 2 factors?
1) Empirical choice
-Aimed at EXPECTED CONTAMINATING BACTERIA
2) Ideal characteristics
What are the 4 ideal characteristics that need to be considered when deciding on a perioperative prophylaxis?
1) Bactericidal
2) Low toxicity/ minimal side effects
3) Cost effective
4) Parenterally administered
-more reliable plasma concentrations
What are 2 procedures that cephalosporins are used for in small animal surgery?
1) Orthopedics
-Skin contamination
-Staphylococcus
-First generation cephalosporin
2) Soft tissue
-Enteric bacteira
-Second generation cephalosporin
What are 4 antimicrobials used in equine surgery?
1) Potassium penicillin
2) Gentamicin
3) Ceftiofur
4) Concurrent NSAID use
-Renal an GI toxicity issues
What are 2 antimicrobials used in foals?
1) Cefazolin or ampicillin
-in times of K-penicillin shortage..
2) Amikacin
What antimicrobial should not be used in young animals? Why?
Enrofloxacin (fluoroquinolone)
-Cartilage damage in young animals
True or false. Ceftiofur can be used in production animal surgery.
False, NOT ANYMORE
What are 2 antimicrobials that can be used in production animal surgery?
1) Penicillin
2) tetracycline
-will cause enamel discoloration
When should antimicrobial prophylaxis be administered?
At least 30 minutes prior to surgical incision but no longer than 60 minutes
-Want adequate TISSUE concentration at time of incision
When do the peak serum and surgical wound fluid concentrations equilibrate?
Approximately 30 minutes after administration and then rapidly decline after that
The choice of antimicrobial for perioperative prophylaxis has to do with what 2 factors?
1) Empirical choice
-Aimed at EXPECTED CONTAMINATING BACTERIA
2) Ideal characteristics
What are the 4 ideal characteristics that need to be considered when deciding on a perioperative prophylaxis?
1) Bactericidal
2) Low toxicity/ minimal side effects
3) Cost effective
4) Parenterally administered
-more reliable plasma concentrations
What are 2 procedures that cephalosporins are used for in small animal surgery?
1) Orthopedics
-Skin contamination
-Staphylococcus
-First generation cephalosporin
2) Soft tissue
-Enteric bacteira
-Second generation cephalosporin
What are 4 antimicrobials used in equine surgery?
1) Potassium penicillin
2) Gentamicin
3) Ceftiofur
4) Concurrent NSAID use
-Renal an GI toxicity issues
What are 2 antimicrobials used in foals?
1) Cefazolin or ampicillin
-in times of K-penicillin shortage..
2) Amikacin
What antimicrobial should not be used in young animals? Why?
Enrofloxacin (fluoroquinolone)
-Cartilage damage in young animals
True or false. Ceftiofur can be used in production animal surgery.
False, NOT ANYMORE
What are 3 antimicrobials that can be used in production animal surgery?
1) Penicillin
2) tetracycline
-will cause enamel discoloration
When should antimicrobial prophylaxis be administered?
At least 30 minutes prior to surgical incision but no longer than 60 minutes
-Want adequate TISSUE concentration at time of incision
When do the peak serum and surgical wound fluid concentrations equilibrate?
Approximately 30 minutes after administration and then rapidly decline after that
When do you stop the administration of antimicrobial prophylaxis?
At end of surgery (SA)
-up to 24 h in equine
-Up to 3 days post-op on equine colics
-Sometimes intra-operative in cattle
What are 7 ways that antimicrobial failure can occur?
1) Inappropriate antimicrobial selection
2) Dosing errors
-too little
-too late
3) Lack of delivery to affected site
4) Bacterial resistance
5) Polymicrobial infection
6) Implant- associated conditions
7) Misdiagnosis of noninfectious cuse
What is the incidence of surgical site infection in clean/clean-contaminated surgery? Contaminated? Dirty?
-Clean/clean contaminated: 5% (SA)
-Contaminated: 12% (SA)
-Dirty: 10.1% (SA)
How long does it take infection to develop with soft tissue procedures? Orthopedic procedures?
Soft tissue: Within 30 days
Orthopedic procedure: w/in 1 year if an implant is placed
What are the 5 classical signs of acute inflammation?
1) Pain
2) Heat
3) Redness
4) Swelling
5) Loss of function
What are 5 ways to detect surgical site infections?
1) seeing the 5 classic signs of acute inflammation
2) Purulent discharge from a surgical incision
3) Deep/organ abscessation
4) Dehiscence
5) Microbial isolation
What are the 4 systemic signs of surgical site infection?
1) **fever
2) Depression
3) Inappetence
4) Limb or organ dysfunction
What are 4 laboratory data that indicates surgical site infection?
1) Leukocytosis (SA)
2) Degenerative left shit (SA)
3) Anemia
4) Elevated fibrinogen
What are 5 radiographic signs of surgical site infection?
1) Mixed pattern
-Lysis & proliferation
2) Abscessation
3) Implant failures
4) Increased fluid density
5) Soft tissue swelling
What are 2 types of cytology and staining that can help diagnose surgical site infection?
1) Abdominocentesis
2) Aspiration of surgical site
What should you do with a deep needle aspirate or biopsy to diagnose a surgical site infection?
Cytology and gram staining
Culture and sensitivity
True or false. Surface contaminants of a wound are usually representative of infective organisms.
False, NOT usually representative of infective organisms
What are the 2 common skin contaminants involved in small animal orthopedic surgery?
1) Coagulase + staphylococcus spp.
2) Beta-hemolytic streptococcus spp.
What are the 2 bacteria involved with soft tissue surgical site infections?
Enterics:
-E. coli
-Klebsiella
What are 3 other common bacteria in small animal surgery (not specific to orthopedics or soft tissue)?
1) Pasteurella multocida
2) Pseudomonas aeruginosa
3) Bacteroides
What are the 5 main bacteria involved with surgical site infection with equine surgery?
1) Staphylococcus spp
2) Enterobacteriaceae
3) Streptococcus spp
4) Pseudomonas aeruginosa
5) Anaerobes
What are 3 things you can do in addition to appropriate antibiotic therapy to treat a surgical site infection?
1) Wound debridement
2) Surgical drainage
3) Implant removal
What are 3 things that help select the antimicrobial for surgical site infections?
1) empirical
2) Culture and sensitivity results
3) Cytology and gram stain
Where are anaerobic infections of surgical sites commonly found?
In areas with mucosal surfaces:
-Oral cavity
-GIT (anaerobic bacteria outnumber the aerobic)
Other common sites:
-abscesses
-Chronic draining tracts
What are 4 less common sites of anaerobic infections of surgical sites?
1) Pleural cavity
2) Bones
3) Respiratory tract
4) Abdominal cavity
More than 70% of obligate anaerobes are caused by what specie of bacteria?
Bacteroides species
What are the 4 facultative aerobic bacteria that make up 80% of anaerobic infections?
1) E. coli* most common
2) Enterobacteriaceae
3) Pasteurella species
4) Staphylococcus intermedius
How do anaerobic and aerobic bacteria have a synergistic relationship?
Aerobes use up the oxygen to make better conditions for the anaerobic bacteria
Anaerobic infections should be treated empirically based on what 3 things?
1) Clinical signs
2) Malodor
3) Cytology and gram staining
What are 5 drug choices for anaerobic infection from surgery?
1) Amoxicillin-clavulonic acid
2) Metronidazole
3) Chloramphenicol
4) Ampicillin
5) Clindamycin
What is the definition of nosocomial infection?
Infections not present or incubating at time of admission
-Develop during or after hospitalization
What are 4 common causes of nosocomial infection?
1) MRSA
2) Salmonella
3) Gram negatives
4) viruses
What are 7 risk factors for developing nosocomial infection?
1) Breaks in aseptic or disinfecting techniques
2) Prolonged hospitalization
-Boarding!
3) Recumbency
4) Catheters
5) Direct contamination of wounds and bandages
6) Excessive use (Misuse) of antibiotics
7) Unclean hospital environment
*WE CAN INFLUENCE THESE