Diagnosis and Management of Surgical Site Infections: Narrative Review

Infection of the wound after surgery is a regular occurrence. Wound infection is a complicated process that involves a molecular interplay between numerous biological processes. Wound infections are associated with a high rate of morbidity and mortality. Surgical site infections are a common surgical complication that affects approximately 3%-6% of all surgical procedures according to different studies. Surgical site infections (SSIs) cause negative consequences in patients, such as prolonged hospitalization and mortality. Each incision causes wound contamination, however there are established techniques to reduce the incidence of SSI. Improved adherence to evidence-based preventative strategies such as adequate antibiotic prophylaxis, in particular, can help to reduce the rate of SSI. The sort of procedure used determines the correct diagnosis of SSI. Early detection, on the other hand, is critical for good management of all surgical operations. Consistent antibiotic therapy, wound drainage, and, if necessary, vigorous wound debridement are all part of the treatment for SSI. Following that, wound management is determined by the location and nature of the infection. This study aims to: Diagnosis and Management of Surgical Site Infections. In this review we will be looking at surgical site infections epidemiology, etiology, diagnosis and management.

Risk factors for unchanged ventricles during pediatric shunt malfunction

OBJECTIVE Children whose ventricles do not change during shunt malfunction present a diagnostic dilemma. This study was performed to identify risk factors for unchanged ventricular size at shunt malfunction. METHODS This retrospective 1:1 age-matched case-control study identified children with shunted hydrocephalus who underwent shunt revision with intraoperative evidence of malfunction at one of the three participating institutions from 1997 to 2019. Cases were defined as patients with a change of < 0.05 in the frontal–occipital horn ratio (FOR) between malfunction and baseline, and controls included patients with FOR changes ≥ 0.05. The presence of infection, abdominal pseudocyst, pseudomeningocele, or wound drainage and lack of baseline cranial imaging at the time of malfunction warranted exclusion. RESULTS Of 450 included patients, 60% were male, 73% were Caucasian, and 67% had an occipital shunt. The median age was 4.3 (IQR 0.97–9.21) years at malfunction. On univariable analysis, unchanged ventricles at malfunction were associated with a frontal shunt (41% vs 28%, p < 0.001), programmable valve (17% vs 9%, p = 0.011), nonsiphoning shunt (85% vs 66%, p < 0.001), larger baseline FOR (0.44 ± 0.12 vs 0.38 ± 0.11, p < 0.001), no prior shunt infection (87% vs 76%, p = 0.003), and no prior shunt revisions (68% vs 52%, p < 0.001). On multivariable analysis with collinear variables removed, patients with a frontal shunt (OR 1.67, 95% CI 1.08–2.70, p = 0.037), programmable valve (OR 2.63, 95% CI 1.32–5.26, p = 0.007), nonsiphoning shunt at malfunction (OR 2.76, 95% CI 1.63–4.67, p < 0.001), larger baseline FOR (OR 3.13, 95% CI 2.21–4.43, p < 0.001), and no prior shunt infection (OR 2.34, 95% CI 1.27–4.30, p = 0.007) were more likely to have unchanged ventricles at malfunction. CONCLUSIONS In a multicenter cohort of children with shunt malfunction, those with a frontal shunt, programmable valve, nonsiphoning shunt, baseline large ventricles, and no prior shunt infection were more likely than others to have unchanged ventricles at shunt failure.

Prevention of hemorrhagic complications during hybrid interference in the sleepy and coronary arteries under conditions of hypo-agregation and hypocaagulation

Hemorrhagic complications in patients after hybrid interventions including percutaneous coronary intervention and carotid endarterectomy are analyzed. Demonstrate a new method of hemostasis and wound drainage after carotid endarterectomy. It was found that at the preoperative stage, the coagulogram parameters were within the normal range, but the aggregatogram showed hypoagregation for two of the four inducers in all 84 operated patients. After the completion of the second stage of revascularization, the absolute partial thrombosed time in all patients was five to six times higher than normal in the coagulogram parameters. According to the aggregatogram, there was a total hypo-aggregation. All acute hematomas after carotid endarterectomy requiring revision were formed in patients with the traditional method of hemostasis and wound drainage after carotid endarterectomy (p = 0.038), which was associated with more frequent damage to the cranial nerves (p = 0.0002). Thus, the combined endpoint, including the indicator of cranial nerve damage + acute hematoma in patients with the traditional method of hemostasis and wound drainage after carotid endarterectomy, significantly exceeded it in patients who used a new tactic (local hemostatics with minimal electrocoagulation and installation of two drains in the paravasal and clitoral space) (p 0.0001). There were no cases of wound complications in the area of carotid endarterectomy. Thus, the new technique of hemostasis and wound drainage after carotid endarterectomy against the background of hypocoagulation and hypoagregation has shown its effectiveness and preventive role in the prevention of hemorrhagic complications, damage to the cranial nerves.

COVID-19 Infection and Cervical Abscess in a Three-Month-Old Infant

A three-month-old infant was referred to the emergency department with fever and a right cervical abscess. Nasopharyngeal swab was positive for SARSCoV- 2 infection. Main causes of infectious abscess and immunodeficiency disorders were ruled out. After a surgical drainage and an antibiotic therapy, clinical conditions of the infant improved, and Staphylococcus Aureus was found in the wound drainage culture. This is a possible, not yet described in infant patients, concurrent clinical manifestation of SARS-CoV-2 infection.

Impact of Weight-Band Dosing of Tinzaparin for Venous Thromboembolism Prophylaxis on Persistent Wound Drainage in Adult Patients Undergoing Hip and Knee Arthroplasty

Background: Persistent wound drainage and venous thromboembolism (VTE) are potential complications of total joint arthroplasty, and these risks can be challenging to balance in clinical practice. Anecdotal observation has suggested that following joint arthroplasty, persistent wound drainage occurs more frequently with higher body weight and higher doses of tinzaparin when compared with lower body weight and lower doses of tinzaparin. Objective: The overall purpose of this study was to describe the impact of a tinzaparin weight-band dosing table for VTE prophylaxis on wound healing, thrombosis, and bleeding outcomes in patients undergoing total joint arthroplasty. Methods: This retrospective chart review included patients who underwent total hip or knee arthroplasty and received tinzaparin for thromboprophylaxis per their weight-banding category. The primary outcome was the incidence of persistent wound drainage. Secondary outcomes include the occurrence of VTE and clinically important bleeding during hospital admission. Results: A total of 231 patients were included in the analysis. There was no significant difference in persistent wound drainage between the 3 weight categories, and there were no differences in rates of VTE or clinically important bleeding. Concurrent use of low-dose acetylsalicylic acid was associated with a 3-fold increased risk of persistent wound drainage (risk ratio = 3.35; 95% CI = 2.14-5.24; P = 0.00003). Conclusion and Relevance: In joint arthroplasty patients, we observed no significant difference in rates of persistent wound drainage between various weight categories receiving different weight-banded doses of tinzaparin. Our results do not suggest that the current weight-band dosing table for tinzaparin needs to be adjusted to optimize patient outcomes.

Neglected tuberculous trochanteric bursitis in an adolescent girl: A case report and literature review

Tuberculous trochanteric bursitis (TTB) is an extremely rare form of extrapulmonary tuberculosis. Due to a low clinical suspicion and poor collaboration among medical professionals, the diagnosis of TTB can be often delayed. In this report, we describe a case of neglected TTB in an adolescent girl that initially presented with right thigh swelling and fluctuance. The patient underwent repeated unsuccessful surgical treatment; however, dull pain and periodic wound drainage remained for eight years. Complete excision of fistula and trochanteric bursa and one year of oral antituberculous drug therapy led to complete recovery. This case report highlights tuberculosis as a diagnostic challenge, when rare localizations are affected. In addition, this report addresses several diagnostic pitfalls and reviews the literature regarding TTB in adolescent patients. Orthopedic surgeons need to consider TTB, when swelling, fluctuance or repeated wound drainage are present on the thigh.

Pre-Operative Bariatric Surgery Imparts An Increased Risk of Infection, Re-Admission and Operative Intervention Following Elective Instrumented Lumbar Fusion

Study Design: Retrospective cohort study. Objectives: To evaluate the impact of bariatric surgery on patient outcomes following elective instrumented lumbar fusion. Methods: A retrospective review of a prospectively collected database was performed. Patients who underwent a bariatric procedure prior to an elective instrumented lumbar fusion were evaluated. Lumbar procedures were performed at a large academic medical center from 1/1/2012 to 1/1/2018. The primary outcome was surgical site infection (SSI) requiring surgical debridement. Secondary outcomes were prolonged wound drainage requiring treatment, implant failure requiring revision, revision secondary to adjacent segment disease (ASD), and chronic pain states. A randomly selected, surgeon and comorbidity-matched group of 59 patients that underwent an elective lumbar fusion during that period was used as a control. Statistical analysis was performed using Student’s two-way t-tests for continuous data, with significance defined as P < .05. Results: Twenty-five patients were identified who underwent bariatric surgery prior to elective lumbar fusion. Mean follow-up was 2.4 ± 1.9 years in the bariatric group vs. 1.5 ± 1.3 years in the control group. Patients with a history of bariatric surgery had an increased incidence of SSI that required operative debridement, revision surgery due to ASD, and a higher incidence of chronic pain. Prolonged wound drainage and implant failure were equivalent between groups. Conclusion: In the present study, bariatric surgery prior to elective instrumented lumbar fusion was associated increased risk of surgical site infection, adjacent segment disease and chronic pain when compared to non-bariatric patients.

Closed Irrigation System for Wound Management of Complicated Ischial Pressure Ulcers

In patients with complicated ischial pressure ulcers, surgical repair is often delayed until the general condition of the patient improves, and in extremely ill patients, surgery might never be performed. Since deep ischial ulcers are usually associated with a profuse discharge, large sinus cavity, and are adjacent to the anus, maintaining effective dressing is challenging for surgeons. In order to manage such ischial ulcers, we devised a closed irrigation system using the Barovac (50–90 mmHg) wound drainage device and a saline infusion set. The system was applied to a 50-year-old paraplegic man who was diagnosed with impending sepsis due to a longstanding ischial ulcer with secondary infection. Using the saline infusion set, we infused 200 mL of saline into the ischial cavity every 6 hours in the ward. After a 10-minute dwell time, the fluid in the cavity, including the exudate and wound debris, was drained continuously through the wound drainage device. This system was very helpful in keeping the patient’s ischial wound clean until his general condition improved and surgical repair could be undertaken. We therefore believe that our closed irrigation system provides an effective, convenient, and inexpensive dressing method for patients with complicated ischial wounds.