IM, intramuscularly; IV, intravenously. Derived from Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116:1736–1754.
Infections are a major source of morbidity in the postoperative period. Risk factors for infectious morbidity include the absence of perioperative antibiotic prophylaxis, contamination of the surgical field from infected tissues or from spillage of large bowel contents, an immunocompromised host, poor nutrition, chronic and debilitating severe illness, poor surgical technique, and preexisting focal or systemic infection. Sources of postoperative infection can include the lung, urinary tract, surgical site, pelvic sidewall, vaginal cuff, abdominal wound, and sites of indwelling intravenous catheters. Early identification and treatment of infection will result in the best outcome for these potentially serious complications.
Although infectious morbidity is an inevitable complication of surgery, the incidence of infections can be decreased by the appropriate use of simple preventive measures. In cases that involve transection of the large bowel, spillage of fecal contents inevitably occurs. A thorough preoperative mechanical and antibiotic bowel preparation in combination with systemic antibiotic prophylaxis will help decrease the incidence of postoperative pelvic and abdominal infections in these patients. The surgeon can further decrease the risk of postoperative infections by using meticulous surgical technique. Blood and necrotic tissue are excellent media for the growth of aerobic and anaerobic organisms. In cases in which there is higher-than-usual potential for serum and blood to collect in spaces that were contaminated by bacterial spill, closed-suction drainage may reduce the risk of infection. Antibiotic therapy, rather than prophylaxis, should be initiated during surgery in patients who have frank intra-abdominal infection or pus. Elective surgical procedures should be postponed in patients who have preoperative infections. In an epidemiologic study conducted by the Centers for Disease Control and Prevention (CDC), the incidence of nosocomial surgical infections ranged from 4.3% in community hospitals to 7% in municipal hospitals (77). Data confirmed this, with an incidence of 2% to 5% (78). Urinary tract infections accounted for approximately 40% of these nosocomial infections. Infections of the skin and wound accounted for approximately one-third of the infections, and respiratory tract infections accounted for approximately 16%. In patients who had any type of infection before surgery, the risk of infection at the surgical wound site increased fourfold. Rates of infection were higher in older patients, in patients with increased length of surgery, and in those with increased length of hospital stay before surgery. The relative risk was three times higher in patients with a community-acquired infection before surgery. These community-acquired infections included infections of the urinary and respiratory tracts.