During a laparoscopic appendectomy, a large bowel injury was caused during trochar placement with spillage of bowel contents into the abdomen.
What class of surgical wound is this?
Surgical wounds are classified based on the presumed magnitude of the bacterial load at the time of surgery. Clean wounds (Class I) include those in which no infection is present; only skin microflora potentially contaminate the wound, and no hollow viscus that contains microbes is entered. Class ID wounds are similar except that a prosthetic device ( eg, mesh or valve) is inserted. Clean/contaminated wounds (Class II) include those in which a hollow viscus, such as the respiratory, alimentary, or genitourinary tracts, with indigenous bacterial flora is opened under controlled circumstances without significant spillage of contents. Contaminated wounds (Class III) include open accidental wounds encountered early after injury, those with extensive introduction of bacteria into a normally sterile area of the body due to major breaks in sterile technique (eg, open cardiac massage), gross spillage of viscus contents such as from the intestine, or incision through inflamed, albeit nonpurulent, tissue. Dirty wounds (Class IV) include traumatic wounds in which a significant delay in treatment has occurred and in which necrotic tissue is present, those created in the presence of overt infection as evidenced by the presence of purulent material, and those created to access a perforated viscus accompanied by a high degree of contamination.
The most appropriate treatment of a 4-cm hepatic abscess is:
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. Formerly, pyogenic liver abscesses 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, Klebsiella 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 similar yeasts cause the majority of fungal hepatic abscesses. Small ( <1 em), 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 above. 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.
Postoperative urinary tract infections (UTIs):
The presence of a postoperative UTI should be considered based on urinalysis demonstrating WBCs or bacteria, a positive test for leukocyte esterase, or a combination of these elements. The diagnosis is established after > 104 CFU/mL of microbes are identified by culture techniques in symptomatic patients, or > 105 CFU/mL in asymptomatic individuals. Treatment for 3 to 5 days with a single antibiotic directed against the most common organisms ( eg, E. Coli, K. pneumoniae) that achieves high levels in the urine is appropriate. Initial therapy is directed by Gram's stain results and is refined as culture results become available. Postoperative surgical patients should have indwelling urinary catheters removed as quickly as possible, typically within 1 to 2 days, as long as they are mobile, to avoid the development of a UTI.
The first step in the evaluation and treatment of a patient with an infected bug bite on the leg with cellulitis, bullae, thin grayish fluid draining from the wound, and pain out of proportion to the physical findings is:
The diagnosis of necrotizing infection 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 be undertaken only in patients in whom the diagnosis is not seriously 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.
What is FALSE regarding intravascular catheter infections?
Many patients who develop intravascular catheter infections are asymptomatic, often exhibiting solely an elevation in the WBC count. Blood cultures obtained from a peripheral site and drawn through the catheter that reveal the presence of the same organism increase the index of suspicion for the presence of a catheter infection. Obvious purulence at the exit site of the skin tunnel, severe sepsis syndrome due to any type of organism when other potential causes have been excluded, or bacteremia due to gram-negative aerobes or fungi should lead to catheter removal. Selected catheter infections due to lowvirulence microbes such as Staphylococcus epidermidis can be effectively treated in approximately 50 to 60% of patients with a 14- to 21-day course of an antibiotic, which should be considered when no other vascular access site exists. Use of systemic antibacterial or antifungal agents to prevent catheter infection is of no utility and is contraindicated.
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