A significant percentage (40% to 50%) of cases of hospital-acquired pneumonia is caused by gram-negative organisms (83). These organisms gain access to the respiratory tract from the oral pharynx. Gram-negative colonization of the oral pharynx is increased in patients in acute care facilities and is associated with the presence of nasogastric tubes, preexisting respiratory disease, mechanical ventilation, and tracheal intubation (92). The use of antimicrobial drugs seems to significantly increase the frequency of colonization of the oral pharynx with gram-negative bacteria.
A thorough lung examination should be included in the assessment of all febrile surgical patients. In the absence of significant lung findings, chest radiography is probably of little benefit in patients at low risk for postoperative pulmonary complications. In patients with pulmonary findings or with risk factors for pulmonary complications, chest radiography should be performed. A sputum sample should be obtained for Gram stain and culture. The treatment should include postural drainage, aggressive pulmonary toilet, and antibiotics. The antibiotic chosen should be effective against both gram-positive and gram-negative organisms. In patients who are receiving assisted ventilation, the antibiotic spectrum should include drugs that are active against Pseudomonas organisms.
Phlebitis Historically, intravenous catheter–related infections were common; the reported incidence is 25% to 35% in the 1980s (93). Because the incidence of catheter-related phlebitis increases significantly after 72 hours, intravenous catheters should be changed at least every 3 days according to the CDC (94). The institution of intravenous therapy teams decreased the incidence of phlebitis by as much as 50% in one study (95). In combination, these measures led to a dramatic decrease in peripheral catheter site infection.
The intravenous site should be inspected daily, and the catheter should be removed if there is any associated pain, redness, or induration. Phlebitis can occur even with close surveillance of the intravenous site. In one study, more than 50% of the cases of phlebitis became evident more than 12 hours after discontinuation of intravenous catheters (96). Less than one-third of patients had symptoms related to the intravenous catheter site 24 hours before the diagnosis of phlebitis.
Phlebitis can be diagnosed based on the presence of fever, pain, redness, induration, or a palpable venous cord. Occasionally, suppuration will be present. Phlebitis is usually self-limited and resolves within 3 to 4 days. The treatment includes application of warm, moist compresses and prompt removal of any catheters from the infected vein. Antibiotic therapy with antistaphylococcal agents should be instituted for catheter-related sepsis. Excision or drainage of an infected vein rarely is necessary.