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Pediatric surgical wound infections
Pediatric Surgical Wound Infections Holly L. Neville, MD, and Kevin P. Lally, MD Postoperative wound infections are one of the most common nosocomial infections in surgical patients and the third most common nosocomial infection in all hospitalized patients. Surgical wound infections commonly increase the need for antibiotics and increase the length of stay and hospital costs. Although this subject has been discussed frequently in the adult literature, fewer than 10 articles exist on the subject in the pediatric patient population, despite the rate of surgical wound infection, which ranges from 3 to 20 percent. Surgical site infections are potentially preventable complications that increase hospital costs as well as patient morbidity and discomfort. Recognizing the patient who is at high risk for a surgical site infection and providing appropriate antibiotic prophylaxis to those patients is an important step in decreasing surgical site infections. This article discusses the risks of surgical site infection specific to pediatric surgical procedures, as well as appropriate antibiotic prophylaxis and treatment. Copyright © 2001 by W.B. Saunders Company
ostoperative wound infection is one of the most common nosocomial infections in surgical patients and the third most common nosocomial infection in all hospitalized patients.1,2 Surgical wound infections commonly increase the need for antibiotics, as well as the length of stay and hospital costs. Although this subject has been discussed frequently in the adult literature, very few articles on the subject focus on the pediatric patient population.3-11 These studies report a rate of surgical wound infection ranging from 3 to 20 percent. However, these studies also include a wide variety of patient populations and types of surgical service (eg, inpatient or outpatient). A review by Martone et al,12 in 1992 showed a postoperative hospital stay of an additional 7.3 days, with an additional $3152 charge, for each surgical site infection. A recent study by Horwitz et al13 looked prospectively at pediatric surgical site infections for all surgeries performed at 3 centers and found a 4.4 percent incidence of surgical site infections. Surgical site infections are potentially preventable complications that increase hospital costs as well as patient morbidity and discomfort. Recognizing the patient who is at high risk for a surgical site infection and providing appropriate antibiotic prophylaxis are important steps in decreasing surgical site infections.
P
From the Department of Surgery, and Division of Pediatric Surgery, University of Texas at Houston Medical School, Houston, TX. Address correspondence to Kevin P. Lally, MD, 6431 Fannin, MSB 5.258, Houston, TX 77030. Copyright © 2001 by W.B. Saunders Company 1045-1870/01/1202-0008$35.00/0 doi:10.1053/spid.2001.22786
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Risk Factors for Surgical Site Infection Wound classification is one part of the preoperative risk assessment for a surgical site infection.2 Wound classification is divided traditionally into clean, clean-contaminated, contaminated, and dirty. The wound classification system is shown in Table 1. Preoperative assessment of risk allows the surgeon to make a decision regarding antibiotic prophylaxis and wound management in a timely, educated fashion, to inform the family, and to document in the patient’s chart if an increased risk for surgical site infection exists. In pediatric surgery, examples of commonly performed operations that fall into class I are inguinal hernia repairs, venous access procedures, excision of soft tissue masses, and umbilical hernia repair. These procedures carry with them a very low risk of surgical site infection (less than 1%).2,14 Common operations resulting in a class II wound may include operations such as a fundoplication, placement of a gastrostomy tube, laparoscopic cholecystectomy, excision of a thyroglossal duct cyst, or incidental appendectomy. With this category of wound, the infection rate is elevated only slightly to 2.5%.2 Class III wounds may result from operations such as appendectomy for acute nonperforated appendicitis or colon surgery with inadequate bowel preparation and spillage. Examples of class IV wounds are perforated appendicitis with peritonitis, traumatic wounds with devitalized tissue, or necrotizing enterocolitis with perforation. Contemporary discussions of stratification of wound infection include additional risk factors that should be considered by the surgical team in determining the appropriateness and the type of antibiotic prophylaxis. The 1999 guidelines of the Centers for Disease Control and Prevention (CDC) for the prevention of hospital infections include several additional risk factors that should be used for pre-
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Table 1. Wound Classification System Wound Category Class I/clean
Class II/clean-contaminated
Class III/contaminated
Class IV/dirty-infected
Description Uninfected wound with no inflammation and the respiratory, alimentary, genital, or uninfected urinary tract is not entered. Clean wounds primarily are closed and drained, when necessary, with closed drainage. Operative wounds after blunt trauma may be included in this category if they meet criteria. Operative wound in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in the category, provided no evidence of infection or major break in technique is encountered. Open, fresh, accidental wounds; operations with major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract; and incisions in which acute, nonpurulent inflammation is encountered. Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera, suggesting that the organisms causing postoperative infection were present in the operative field before operation.
Data from Mangram et al,2 Garner,59 and Simmons.60
operative stratification of postoperative surgical site infection.2 They include diabetes, concurrent remote site infection or colonization, use of systemic corticosteroids, extremes of age, malnutrition, duration of operation, and perioperative transfusion of blood products. Diabetes often is suggested as a risk factor for surgical site infection, despite the paucity of data. However, a welldocumented fact is that optimal white blood cell function can be achieved with serum glucose levels controlled below 200 mg/dL.15,16 Thus, although additional antibiotic prophylaxis may not be warranted, careful postoperative glucose control should be attained. Similarly, systemic corticosteroid use has not been shown to increase the risk for surgical site infection, despite its clear effects on wound healing.17 In a patient who has received long-term systemic corticosteroids and in whom wound healing is of great concern, oral vitamin A may be given to reverse the wound healing deficit. Concurrent remote site infection or colonization is a known risk factor for surgical site infections. Several studies revealed a significantly increased odds ratio for postsurgical site infection in the face of an untreated remote infection.18,19 When possible, patients with a concurrent remote bacterial infection should be treated adequately before undergoing surgery. In the urgent or emergency setting, appropriate antibiotic therapy should be given preoperatively as well as during the postoperative period. Colonization of mucous membranes, particularly nasal colonization with Staphylococcus aureus, has been well documented as a risk for surgical site infection.20,21 Affected patients have a twofold to 10-fold increase in the risk of developing a surgical site infection with S aureus.20 Patients with frequent or lengthy hospitalizations should be screened for nasal colonization and treated with mupirocin (Bactroban; SmithKline Beecham Pharmaceuticals, Research Triangle Park, NC) intranasally to eradicate
the infection.22 This treatment is effective in reducing the risk of surgical site infection in patients with nasal colonization.23 Malnutrition has long been considered a risk factor for surgical site infections, and numerous studies have attempted to evaluate optimization of nutritional status in the preoperative period in order to decrease the risk of postoperative complications.24-27 None of these studies in adults has shown definitively a decreased risk with preoperative administration of enteral or parenteral feeds.17 No similar studies have been performed for pediatric patients, although one can presume that profound malnutrition will result in delayed wound healing, which may predispose the patient to postoperative surgical site infections. Unfortunately, administration of parenteral or enteral nutrition in the immediate preoperative period is unlikely to reverse this risk. Most pediatric surgeons, when performing even low-risk procedures in a neonate, will prescribe prophylactic antibiotics.28 Neonates appear to have a higher incidence of surgical site infections, with rates of 10 to 20 percent for clean or clean-contaminated wounds.11 This incidence has been attributed to abnormalities of polymorphonuclear cell function.29 Whether routine prophylactic antibiotics are beneficial in this age group remains unclear. Davenport and Deig11 suggest that appropriate prophylaxis administered just before operation decreases the risk of surgical site infection in this age group. This argument is countered by Horwitz et al,13 who found no difference in infection rates for clean cases in the neonate based on administration of prophylactic antibiotics. Perioperative blood transfusion has been shown to increase the risk of surgical site infection. Because of the variables associated with perioperative transfusion (increased length of operation, patient comorbidities), whether transfusion in and of itself is a risk factor for
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surgical site infection remains unclear.2 Based on the literature on organ transplantation, a plausibility is that the immunosuppressive effects of non–leukocyte-depleted packed red blood cells may increase the risk of surgical site infection.30-32 However, in the pediatric setting, the dosing of packed red blood cells rarely is a variable that can be adjusted by the surgeon or anesthetist to decrease the risk of wound infection. Additional risk factors that should be taken into account include the length of operative time; malignancy; severe immunocompromise or immunologic disease; and the use of foreign material, including silk suture, in wounds with high levels of bacterial contamination.2
tomy tube placement, because of concerns of increased infection. A recent study by Pittman et al39 reviewed patients who had a shunt and also had undergone abdominal operations. This series, which contained a wide variety of cases (clean, clean-contaminated, and contaminated cases), showed no increase in shunt complication secondary to intra-abdominal instrumentation, despite irregular use of prophylactic antibiotics. Based on this series, providing prophylactic antibiotics that are appropriate for the intraabdominal operation, without additional antibiotic administration because of the presence of a shunt, most likely is sufficient.
Infections and Commonly Isolated Organisms
Appendectomy is one of the few operations performed in the pediatric population with data to support or dissuade the use of perioperative antibiotics.40-42 The pathology and bacteriology of appendicitis is well known. Because the bacteria found in the appendix are similar to those found in the colon, prophylaxis and treatment, when indicated, should be directed at colonic flora. Children with a nonperforated appendix are at a very small risk of surgical site infection because the wound is categorized as clean-contaminated. These children should receive a single preoperative antibiotic dose, such as a third-generation cephalosporin, to provide gram-negative and anaerobic coverage.43 The high-risk patient with a perforated appendix should receive treatment for established peritonitis. These patients should not be given prophylaxis, but instead therapy for a preexisting intra-abdominal infection.44 Although no well-supported recommendations exist for the length of antibiotic therapy in perforated appendix, most surgeons treat either until the patient has a normal leukocyte count and is afebrile, or for 7 to 10 days.45 The authors currently treat a perforated appendix with an aminoglycoside and metronidazole for 7 days, at which time a leukocyte count is obtained. If the cell count is normal, the antibiotics are stopped. Peritoneal culture, at the time of operation, does not seem to add much to patient care. For the most part, the microbial pathogens can be predicted, and routine cultures have not been shown to affect therapy.46 For these reasons, cultures can be reserved for those patients with wound infection or need for reoperation or drainage because of failure of therapy.47 Incidental appendectomy should not be performed routinely except when indicated—for example, the Ladd’s procedure— because of the increased risk of surgical site infection.48
Appendectomy
Data from the CDC guidelines for prevention of surgical site infection reveal that the most common pathogens from wound infections are Staphylococcus aureus, coagulase-negative Staphylococcus, Enterococcus, Escherichia coli, and ␣-hemolytic Streptococcus.2 Concerns include the increasing incidence of methacillin-resistant Staphylococcus aureus and candidal species. Bhattacharyya and Kosioske33 confirmed that these organisms are common pathogens in pediatric surgical site infections. Antibiotic prophylaxis should be aimed at these organisms and should be based on likely contaminants. For instance, operations that involve the skin or soft tissues should have antibiotics aimed at staphylococcal and streptococcal species, whereas operations that involve the colon or biliary tract should have prophylaxis directed at gram-negative bacilli and anaerobes.
Specific Pediatric Surgical Procedures As previously discussed, very little of the literature on surgical site infections focuses or even includes the pediatric population. However, some of the literature looks specifically at the commonly performed procedures in the pediatric population and may lend insight into appropriate perioperative care and administration of antibiotics.
Ventriculoperitoneal Shunt Insertion of a ventriculoperitoneal shunt is one of the operations performed most commonly in the pediatric population. Although the procedure itself usually is performed by a pediatric neurosurgeon, these children often are under the care of, or have involvement by, other pediatric specialists. Current literature suggests a 5 to 10 percent incidence of surgical site or shunt infection.34-36 The morbidity and even mortality of shunt infections is very high, and the treatment of choice remains removal of the infected shunt and antibiotic therapy. Several centers have shown benefit from the institution of antimicrobial prophylaxis in these children, yet the risk may still exceed the predicted 1 to 2 percent of wound infections seen in most clean surgical cases.37,38 Most neurosurgeons avoid combined procedures, such as shunt placement and fundoplication with gastros-
Pyloromyotomy in the Treatment of Infantile Pyloric Stenosis Several studies discuss the reported incidence of wound infection after pyloromyotomy in infants. However, the risk varies widely from less than 1 percent to 12 percent.49,50 Whether patients undergoing pyloromyotomy will benefit from prophylactic antibiotics is difficult to determine. With no entrance into the gastrointestinal system, the expected complication rate should be very low; however, because of
Pediatric Surgical Wound Infections preexisting obstruction, some authors recommend routine prophylaxis.28 A recent study by Leinwand et al51 reviewed 344 patients who underwent open pyloromyotomy. The study was designed to compare the complication rate, including surgical site infections, between the periumbilical approach and the right upper-quadrant approach. The authors reported an overall wound infection rate of 2.6 percent, which was decreased to 1.8 percent with appropriate preoperative antibiotic administration. Interestingly, the overall wound complication rate was statistically higher in the periumbilical group (6.7% v 2.8%, P ⬍ .001), but this difference was not statistically significant in those treated with prophylactic antibiotics. Although no solid data exist, laparoscopic pyloromyotomy would be expected to have a low risk of infection. If prophylaxis is given, a single preoperative dose of a first-generation cephalosporin is sufficient coverage.
Fundoplication/Gastrostomy Tube Placement Fundoplication should have a very low rate of surgical site infection, similar to that seen with pyloromyotomy, when performed without a gastrostomy tube. Gastrostomy tubes can be placed by several techniques: laparoscopically, open, and percutaneous endoscopic gastrostomy placement. The gastric flora in children requiring fundoplication and gastrostomy tube placement are variable. Wound infections cultured after fundoplication or gastrostomy tube have a more complex microbiologic profile. The most common organisms include E coli, Peptostreptococcus, Enterococcus, Bacteroides, Staphylococcus, and Candida.52 Unfortunately, among these organisms, -lactamase producers frequently were present, which may render these relatively common infections more difficult to treat.52 The risk of a surgical site infection after gastrostomy is approximately 8 percent and has been reported to be as high as 50 percent in children with malignancy or end-stage acquired immunodeficiency syndrome.53 The incidence of complications does not appear to be different at primary operation based on technique (open, laparoscopic, percutaneous endoscopic).54 Interestingly, one of the most commonly performed office procedures— exchange of a percutaneous endoscopically placed gastrostomy tube to a skin level gastrostomy—also is fraught with complications, having a 20 percent complication rate of tract disruption.55 Another study showed a 7.3 percent rate of wound infection and cellulitis after catheter replacement.56 Should the physician encounter any difficulty during this procedure, fluoroscopic confirmation of tube placement should be obtained before resuming feeds. Before fundoplication or gastrostomy is performed, particularly in a high-risk patient such as one with cancer or significant immunocompromise, a single dose of a third-generation cephalosporin should be considered. In a patient who is known or suspected to have skin/nasal colonization with methicillin-resistant S aureus, coverage should be expanded to an antibiotic that does not contain a -lactam. Antibiotic prophylaxis should not differ for patients who undergo a fundoplication, fundoplication with gastrostomy tube, or placement of a gastrostomy tube alone.
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Hernia Hernia repair in the pediatric population has a very low infection rate, cited at less than 1 percent in most studies.13 Prophylaxis should be considered only in the high-risk patient or the unusual older patient who requires insertion of mesh for repair of the hernia.57
Antibiotic Prophylaxis Based on the CDC guidelines, prophylaxis with antibiotics should be considered for clean-contaminated or contaminated cases, operations in which a foreign material is implanted, patients with heart valve disease, and patients who fall into high-risk groups.2 Despite lack of solid data supporting the use of routine antibiotic prophylaxis in neonates, most pediatric surgeons are not likely to abandon this practice unless future studies show it to be unnecessary or harmful.28 Prophylaxis should be carefully directed to the organisms most likely to cause infection. In general, for incisions involving skin and soft tissues, antibiotic coverage should be directed at gram-positive organisms. Use of an antibiotic effective against -lactamase producers should be considered when dealing with a patient who has had either longterm or frequent hospitalizations. For incisions involving the upper intestinal tract, antibiotics should be directed at gram-negative bacilli and may include coverage for anaerobes. An agent such as cefoxitin or cefotetan would provide adequate coverage. Operations that involve the appendix or colon should be preceded by administration of an agent that is effective against gram-negative bacilli and anaerobes. Again, a third-generation cephalosporin is adequate. However, if peritonitis or active infection is anticipated or encountered, antibiotic coverage should be broadened and may include an aminoglycoside coupled with metronidazole or clindamycin or, in the young adult, a fluoroquinolone coupled with metronidazole or clindamycin. When antimicrobial prophylaxis is deemed appropriate, the antibiotic should be given within 2 hours of the time of incision and redosed according to the drug’s half-life should the operation be lengthy.28,58 Many surgeons prefer to have the antibiotic dosed once the patient is in the operating suite to ensure that a long period has not passed since the antimicrobial agent was administered. For dirty, class IV, cases, antibiotic prophylaxis should not be prescribed. Instead, the patient should receive antimicrobial therapy directed against the appropriate organisms both preoperatively and postoperatively.
Conclusion Despite numerous advances in the fields of medicine, surgery, and infectious disease, surgical site infection remains a source of postoperative morbidity and contributes to increased hospital costs and the patient’s length of stay. Inappropriate use of antimicrobial therapy is suspected to contribute to bacterial resistance now frequently encountered in both the inpatient and outpatient settings through-
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out much of the United States. The current reported incidence of surgical site infection in the pediatric population is approximately 4.5 percent.13 Preoperative consideration of the patient’s risk factors for surgical site infection, including wound class as well as additional risk factors, should be taken. This consideration will allow for proper timing for administration of the antibiotic, as well as time to document in the patient’s record and notify the patient’s caretaker of the increased risk for surgical site infection and potential increased postoperative morbidity or mortality. Antibiotic prophylaxis is appropriate in class II to IV wounds as well as class I wounds that occur in high-risk patients or patients who are receiving an implantable device. For antibiotic prophylaxis to be effective, it must be dosed within 2 hours of surgery, which is best accomplished via dosing either in day surgery holding or in the operating room after induction of anesthesia.
References 1. Haley RW, Culver DH, White JW, et al: The nationwide nosocomial infection rate: A new need for vital statistics. Am J Epidemiol 121:159-167, 1985 2. Mangram AJ, Horan TC, Pearson ML, et al: Guidelines for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 27:97-132, 1999 3. Cooper RG, Sumner C: Hospital infection data from a children’s hospital. Med J Aust 2:1110-1113, 1970 4. Doig CM, Wilkinson AW: Wound infections in a children’s hospital. Br J Surg 63:647-650, 1976 5. Davis SD, Sobocinski K, Hoffmann RG, et al: Postoperative wound infections in a children’s hospital. Pediatr Infect Dis 3:114-116, 1984 6. Ford-Jones EL, Mindorf DM, Langley JM, et al: Epidemiologic study of 4684 hospital-acquired infections in pediatric patients. Pediatr Infect Dis J 8:668-675, 1989 7. Roy TE, McDonald S, Patrick ML, et al: A survey of hospital infection in a pediatric hospital. Can Med Assoc J 87:531-538, 1962 8. Roy TE, McDonald S, Patrick ML, et al: A survey of hospital infection in a pediatric hospital. Can Med Assoc J 87:592-599, 1962 9. Roy TE, McDonald S, Patrick ML, et al: A survey of hospital infection in a pediatric hospital. Can Med Assoc J 87:656-660, 1962 10. Davenport M, Doig CM: Wound infection in pediatric surgery: A study in 1094 neonates. J Pediatr Surg 28:26-30, 1993 11. Sharma LK, Sharma PK: Postoperative wound infection in a pediatric surgical service. J Pediatr Surg 21:889-891, 1986 12. Martone WJ, Jarvis WR, Culver DH, et al: Incidence and nature of endemic and epidemic nosocomial infections, in Bennett JV, Brachman PS (eds): Hospital Infections (ed 3). Boston, MA, Little, Brown, 1992, pp 577-596 13. Horwitz JR, Chwals WJ, Doski JJ, et al: Pediatric wound infections, a prospective multicenter trial. Ann Surg 227:553-558, 1998 14. Cruse PJE, Foord R: A five-year prospective study of 23,649 surgical wounds. Arch Surg 107:206-210, 1973 15. Metz SA: Altered arachadonic acid synthesis and lipid peroxidation in diabetes mellitus: Possible roles in leukocyte dysfunc-
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tion and other cellular defects. Med Hypotheses 12:341-357, 1983 Marhoffer W, Stein M, Maeser D, et al: Impairment of polymorphonuclear leukocyte function and metabolic control of diabetes. Diabetes Care 15:256-260, 1992 Hunt TK, Hopf HW: Wound healing and wound infections: What surgeons and anesthesiologists can do. Surg Clin North Am 77:587-606, 1997 Tran TS, Jamulitrat S, Chongsuvivatwong V, et al: Risk factors for postcesarean surgical site infection. Obstet Gynecol 95:367371, 2000 Velasco E, Thuler LC, Martins CA, et al: Risk factors for infectious complications after abdominal surgery for malignant disease. Am J Infect Control 24:1-6, 1996 Perl TM, Roy MC: Postoperative wound infections: Risk factors and role of staphylococcus aureus nasal carriage. J Chemother 7:29-35, 1995 Raz R, Miron D, Colodner R, et al: A 1-year trial of mupirocin in the prevention of recurrent staphylococcal nasal colonization and skin infection. Arch Intern Med 156:1109-1112, 1996 Soto NE, Vaghijimal A, Stahl-Avicolli A, et al: Bacitracin versus mupirocin for staphylococcus aureus nasal colonization. Infect Control Hosp Epidemiol 20:351-353, 1999 The Mupirocin Study Group: Nasal mupirocin prevents staphylococcus aureus exit-site infection during peritoneal dialysis. J Am Soc Nephrol 7:2403-2408, 1996 Delaney H, Demetrious A, Teh E, et al: Effect if early postoperative nutritional support on skin wound and colon anastamotic healing. JPEN J Parenter Enteral Nutr 14:357-361, 1990 Hestin MJ, Latkany L, Leung D, et al: A prospective, randomized trial of early enteral feeding after resection of upper gastrointestinal malignancy. Ann Surg 226:567-577, 1997 Heys SD, Walker LG, Smith I, et al: Enteral nutritional supplementation with key nutrients in patients with critical illness and cancer: A metaanalysis of randomized controlled clinical trials. Ann Surg 229:467-477, 1999 Senkal M, Zumtobel V, Bauer KH, et al: Outcome and costeffectiveness of perioperative enteral immunonutrition in patients undergoing elective upper gastrointestinal tract surgery: A prospective randomized study. Arch Surg 134:1309-1316, 1999 Dellinger EP, Gross PA: Quality standard for antimicrobial prophylaxis in surgical procedures. Infect Control Hosp Epidemiol 15:182-188, 1994 Merry C, Puri P, Reen DJ: Defective neutrophil actin polymerization and chemotaxis in stressed newborns. J Pediatr Surg 31:481-485, 1996 Chaverns BM, Sullivan EK, Tejani A, et al: Pre-transplant blood transfusion and renal allograft outcome: A report of the North American Pediatric Renal Transplant Cooperative Study. Pediatr Tranplant 1:22-28, 1997 Reinsmoen NL, Matas AJ, Donaldson L, et al: Impact of transfusions and acute rejection on posttransplantation donor antigen-specific responses in two study populations. Cooperative Clinical Trial in Transplantation Research Group. Transplantation 67:697-702, 1999 Galvao MM, Peixinho ZF, Mendes NF, et al: Stored blood—An effective immunosuppressive method for transplantation of kidneys from unrelated donors: An 11-year follow-up. Braz J Med Biol Res 30:727-734, 1997 Bhattacharyya N, Kosioske AM: Postoperative wound infection in pediatric surgical patients: A study of 676 infants and children. J Pediatr Surg 25:125-129, 1990
Pediatric Surgical Wound Infections 34. Borgbjerg BM, Gjerris F, Albeck MJ, et al: Risk of infection after cerebrospinal fluid shunt: An analysis of 884 first-time shunts. Acta Neurochir 136:1-7, 1995 35. Williams DG, Hayes J, McCool S: Shunt infections in children: Presentation and management. J Neurosci Nurs 28:155-162, 1996 36. Horgan MA, Piatt JH Jr: Shaving of the scalp may increase the rate of infection in CSF shunt surgery. Pediatr Neurosurg 26:180-184, 1997 37. Choux M, Genitori L, Land D, et al: Shunt implantation: Reducing the incidence of shunt infection. J Neurosurg 77:875880, 1992 38. Rieder MJ, Frewen TC, Del Maestro RF, et al: The effect of cephalothin prophylaxis on postoperative ventriculo-peritoneal shunt infections. CMAJ 136:935-938, 1987 39. Pittman T, Williams D, Weber TR, et al: Risk of abdominal operations in children with ventriculoperitoneal shunts. J Pediatr Surg 27:1051-1053, 1992 40. Altemeier WA: The bacterial flora of acute perforated appendicitis with peritonitis. Ann Surg 107:517-528, 1938 41. Bohnen JM, Solomkin JS, Dellinger EP, et al: Guidelines for clinical care: Anti-infective agents for intra-abdominal infection. A surgical infection society policy statement. Arch Surg 127:83-89, 1992 42. Baron EJ, Bennion R, Thompson J, et al: A microbiological comparison between acute and complicated appendicitis. Clin Infect Dis 14:227-231, 1992 43. Liberman MA, Gleason KL, Frame S, et al: Single-dose cefotetan or cefoxitin versus multiple-dose as prophylaxis in patients undergoing appendectomy for acute nonperforated appendicitis. J Am Coll Surg 180:77-80, 1995 44. Doraiswamy NV: The neutrophil count in childhood acute appendicitis. Br J Surg 64:342-344, 1977 45. Keller MS, McBride WJ, Vane DW: Management of complicated appendicitis: A rational approach based on clinical course. Arch Surg 131:261-264, 1996 46. Mosdell DM, Morris DM, Fry DE: Peritoneal cultures and antibiotic therapy in pediatric perforated appendicitis. Am J Surg 167:313-316, 1994 47. Bilik R, Burnweit C, Shandling B: Is abdominal cavity culture of any value in appendicitis? Am J Surg 175:267-270, 1998
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48. Fisher KS, Ross DS: Guidelines for therapeutic decision in incidental appendectomy. Surg Gynecol Obstet 171:95-98, 1990 49. Nour S, MacKinnon AE, Dickson JA, et al: Antibiotic prophylaxis for infantile pyloromyotomy. J R Coll Surg Edinb 41:178180, 1996 50. Hulka F, Harrison MW, Campbell TJ, et al: Complications of pyloromyotomy for infantile hypertrophic pyloric stenosis. Am J Surg 173:450-452, 1997 51. Leinwand MJ, Shaul DB, Anderson KD: The umbilical fold approach to pyloromyotomy: Is it a safe alternative to the right upper-quadrant approach? J Am Coll Surg 189:362-367, 1999 52. Brooks I: Microbiology of gastrostomy site wound infections in children. J Med Microbiol 43:221-223, 1995 53. Cappell MS, Godil A: A multicenter case-controlled study of percutaneous endoscopic gastrostomy in HIV-seropositive patients. Am J Gastroenterol 81:2059-2066, 1993 54. Moller P, Lindberg CG, Zilling T: Gastrostomy by various techniques: Evaluation of indications, outcome and complications. Scand J Gastroenterol 34:1050-1054, 1999 55. Romero R, Martinez FL, Robinson SY, et al: Complicated PEG-to-skin level gastrostomy conversions: Analysis of risk factors for tract disruption. Gastrointest Endosc 44:230-234, 1996 56. Fox VL, Abel SD, Malas S, et al: Complications following percutaneous endoscopic gastrostomy and subsequent catheter replacement in children and young adults. Gastrointest Endosc 45:64-71, 1997 57. Platt R, Zucker JR, Zaleznik DF, et al: Prophylaxis against wound infection following herniorrhaphy or breast surgery. J Infect Dis 166:556-560, 1992 58. Martin C: Antimicrobial prophylaxis in surgery. General concepts and clinical guidelines. French Study Group on Antimicrobial Prophylaxis in Surgery, French Society of Anesthesia and Intensive Care. Infect Control Hosp Epidemiol 15:463-471, 1994 59. Garner JS: CDC guideline for prevention of surgical wound infections, 1985. Infect Control 7:193-200, 1986 60. Simmons BP: Guideline for prevention of surgical wound infections. Am J Infect Control 4:133-143, 1983
ostoperative wound infection is one of the most common nosocomial infections in surgical patients and the third most common nosocomial infection in all hospitalized patients.1,2 Surgical wound infections commonly increase the need for antibiotics, as well as the length of stay and hospital costs. Although this subject has been discussed frequently in the adult literature, very few articles on the subject focus on the pediatric patient population.3-11 These studies report a rate of surgical wound infection ranging from 3 to 20 percent. However, these studies also include a wide variety of patient populations and types of surgical service (eg, inpatient or outpatient). A review by Martone et al,12 in 1992 showed a postoperative hospital stay of an additional 7.3 days, with an additional $3152 charge, for each surgical site infection. A recent study by Horwitz et al13 looked prospectively at pediatric surgical site infections for all surgeries performed at 3 centers and found a 4.4 percent incidence of surgical site infections. Surgical site infections are potentially preventable complications that increase hospital costs as well as patient morbidity and discomfort. Recognizing the patient who is at high risk for a surgical site infection and providing appropriate antibiotic prophylaxis are important steps in decreasing surgical site infections.
P
From the Department of Surgery, and Division of Pediatric Surgery, University of Texas at Houston Medical School, Houston, TX. Address correspondence to Kevin P. Lally, MD, 6431 Fannin, MSB 5.258, Houston, TX 77030. Copyright © 2001 by W.B. Saunders Company 1045-1870/01/1202-0008$35.00/0 doi:10.1053/spid.2001.22786
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Risk Factors for Surgical Site Infection Wound classification is one part of the preoperative risk assessment for a surgical site infection.2 Wound classification is divided traditionally into clean, clean-contaminated, contaminated, and dirty. The wound classification system is shown in Table 1. Preoperative assessment of risk allows the surgeon to make a decision regarding antibiotic prophylaxis and wound management in a timely, educated fashion, to inform the family, and to document in the patient’s chart if an increased risk for surgical site infection exists. In pediatric surgery, examples of commonly performed operations that fall into class I are inguinal hernia repairs, venous access procedures, excision of soft tissue masses, and umbilical hernia repair. These procedures carry with them a very low risk of surgical site infection (less than 1%).2,14 Common operations resulting in a class II wound may include operations such as a fundoplication, placement of a gastrostomy tube, laparoscopic cholecystectomy, excision of a thyroglossal duct cyst, or incidental appendectomy. With this category of wound, the infection rate is elevated only slightly to 2.5%.2 Class III wounds may result from operations such as appendectomy for acute nonperforated appendicitis or colon surgery with inadequate bowel preparation and spillage. Examples of class IV wounds are perforated appendicitis with peritonitis, traumatic wounds with devitalized tissue, or necrotizing enterocolitis with perforation. Contemporary discussions of stratification of wound infection include additional risk factors that should be considered by the surgical team in determining the appropriateness and the type of antibiotic prophylaxis. The 1999 guidelines of the Centers for Disease Control and Prevention (CDC) for the prevention of hospital infections include several additional risk factors that should be used for pre-
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Table 1. Wound Classification System Wound Category Class I/clean
Class II/clean-contaminated
Class III/contaminated
Class IV/dirty-infected
Description Uninfected wound with no inflammation and the respiratory, alimentary, genital, or uninfected urinary tract is not entered. Clean wounds primarily are closed and drained, when necessary, with closed drainage. Operative wounds after blunt trauma may be included in this category if they meet criteria. Operative wound in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in the category, provided no evidence of infection or major break in technique is encountered. Open, fresh, accidental wounds; operations with major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the gastrointestinal tract; and incisions in which acute, nonpurulent inflammation is encountered. Old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera, suggesting that the organisms causing postoperative infection were present in the operative field before operation.
Data from Mangram et al,2 Garner,59 and Simmons.60
operative stratification of postoperative surgical site infection.2 They include diabetes, concurrent remote site infection or colonization, use of systemic corticosteroids, extremes of age, malnutrition, duration of operation, and perioperative transfusion of blood products. Diabetes often is suggested as a risk factor for surgical site infection, despite the paucity of data. However, a welldocumented fact is that optimal white blood cell function can be achieved with serum glucose levels controlled below 200 mg/dL.15,16 Thus, although additional antibiotic prophylaxis may not be warranted, careful postoperative glucose control should be attained. Similarly, systemic corticosteroid use has not been shown to increase the risk for surgical site infection, despite its clear effects on wound healing.17 In a patient who has received long-term systemic corticosteroids and in whom wound healing is of great concern, oral vitamin A may be given to reverse the wound healing deficit. Concurrent remote site infection or colonization is a known risk factor for surgical site infections. Several studies revealed a significantly increased odds ratio for postsurgical site infection in the face of an untreated remote infection.18,19 When possible, patients with a concurrent remote bacterial infection should be treated adequately before undergoing surgery. In the urgent or emergency setting, appropriate antibiotic therapy should be given preoperatively as well as during the postoperative period. Colonization of mucous membranes, particularly nasal colonization with Staphylococcus aureus, has been well documented as a risk for surgical site infection.20,21 Affected patients have a twofold to 10-fold increase in the risk of developing a surgical site infection with S aureus.20 Patients with frequent or lengthy hospitalizations should be screened for nasal colonization and treated with mupirocin (Bactroban; SmithKline Beecham Pharmaceuticals, Research Triangle Park, NC) intranasally to eradicate
the infection.22 This treatment is effective in reducing the risk of surgical site infection in patients with nasal colonization.23 Malnutrition has long been considered a risk factor for surgical site infections, and numerous studies have attempted to evaluate optimization of nutritional status in the preoperative period in order to decrease the risk of postoperative complications.24-27 None of these studies in adults has shown definitively a decreased risk with preoperative administration of enteral or parenteral feeds.17 No similar studies have been performed for pediatric patients, although one can presume that profound malnutrition will result in delayed wound healing, which may predispose the patient to postoperative surgical site infections. Unfortunately, administration of parenteral or enteral nutrition in the immediate preoperative period is unlikely to reverse this risk. Most pediatric surgeons, when performing even low-risk procedures in a neonate, will prescribe prophylactic antibiotics.28 Neonates appear to have a higher incidence of surgical site infections, with rates of 10 to 20 percent for clean or clean-contaminated wounds.11 This incidence has been attributed to abnormalities of polymorphonuclear cell function.29 Whether routine prophylactic antibiotics are beneficial in this age group remains unclear. Davenport and Deig11 suggest that appropriate prophylaxis administered just before operation decreases the risk of surgical site infection in this age group. This argument is countered by Horwitz et al,13 who found no difference in infection rates for clean cases in the neonate based on administration of prophylactic antibiotics. Perioperative blood transfusion has been shown to increase the risk of surgical site infection. Because of the variables associated with perioperative transfusion (increased length of operation, patient comorbidities), whether transfusion in and of itself is a risk factor for
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surgical site infection remains unclear.2 Based on the literature on organ transplantation, a plausibility is that the immunosuppressive effects of non–leukocyte-depleted packed red blood cells may increase the risk of surgical site infection.30-32 However, in the pediatric setting, the dosing of packed red blood cells rarely is a variable that can be adjusted by the surgeon or anesthetist to decrease the risk of wound infection. Additional risk factors that should be taken into account include the length of operative time; malignancy; severe immunocompromise or immunologic disease; and the use of foreign material, including silk suture, in wounds with high levels of bacterial contamination.2
tomy tube placement, because of concerns of increased infection. A recent study by Pittman et al39 reviewed patients who had a shunt and also had undergone abdominal operations. This series, which contained a wide variety of cases (clean, clean-contaminated, and contaminated cases), showed no increase in shunt complication secondary to intra-abdominal instrumentation, despite irregular use of prophylactic antibiotics. Based on this series, providing prophylactic antibiotics that are appropriate for the intraabdominal operation, without additional antibiotic administration because of the presence of a shunt, most likely is sufficient.
Infections and Commonly Isolated Organisms
Appendectomy is one of the few operations performed in the pediatric population with data to support or dissuade the use of perioperative antibiotics.40-42 The pathology and bacteriology of appendicitis is well known. Because the bacteria found in the appendix are similar to those found in the colon, prophylaxis and treatment, when indicated, should be directed at colonic flora. Children with a nonperforated appendix are at a very small risk of surgical site infection because the wound is categorized as clean-contaminated. These children should receive a single preoperative antibiotic dose, such as a third-generation cephalosporin, to provide gram-negative and anaerobic coverage.43 The high-risk patient with a perforated appendix should receive treatment for established peritonitis. These patients should not be given prophylaxis, but instead therapy for a preexisting intra-abdominal infection.44 Although no well-supported recommendations exist for the length of antibiotic therapy in perforated appendix, most surgeons treat either until the patient has a normal leukocyte count and is afebrile, or for 7 to 10 days.45 The authors currently treat a perforated appendix with an aminoglycoside and metronidazole for 7 days, at which time a leukocyte count is obtained. If the cell count is normal, the antibiotics are stopped. Peritoneal culture, at the time of operation, does not seem to add much to patient care. For the most part, the microbial pathogens can be predicted, and routine cultures have not been shown to affect therapy.46 For these reasons, cultures can be reserved for those patients with wound infection or need for reoperation or drainage because of failure of therapy.47 Incidental appendectomy should not be performed routinely except when indicated—for example, the Ladd’s procedure— because of the increased risk of surgical site infection.48
Appendectomy
Data from the CDC guidelines for prevention of surgical site infection reveal that the most common pathogens from wound infections are Staphylococcus aureus, coagulase-negative Staphylococcus, Enterococcus, Escherichia coli, and ␣-hemolytic Streptococcus.2 Concerns include the increasing incidence of methacillin-resistant Staphylococcus aureus and candidal species. Bhattacharyya and Kosioske33 confirmed that these organisms are common pathogens in pediatric surgical site infections. Antibiotic prophylaxis should be aimed at these organisms and should be based on likely contaminants. For instance, operations that involve the skin or soft tissues should have antibiotics aimed at staphylococcal and streptococcal species, whereas operations that involve the colon or biliary tract should have prophylaxis directed at gram-negative bacilli and anaerobes.
Specific Pediatric Surgical Procedures As previously discussed, very little of the literature on surgical site infections focuses or even includes the pediatric population. However, some of the literature looks specifically at the commonly performed procedures in the pediatric population and may lend insight into appropriate perioperative care and administration of antibiotics.
Ventriculoperitoneal Shunt Insertion of a ventriculoperitoneal shunt is one of the operations performed most commonly in the pediatric population. Although the procedure itself usually is performed by a pediatric neurosurgeon, these children often are under the care of, or have involvement by, other pediatric specialists. Current literature suggests a 5 to 10 percent incidence of surgical site or shunt infection.34-36 The morbidity and even mortality of shunt infections is very high, and the treatment of choice remains removal of the infected shunt and antibiotic therapy. Several centers have shown benefit from the institution of antimicrobial prophylaxis in these children, yet the risk may still exceed the predicted 1 to 2 percent of wound infections seen in most clean surgical cases.37,38 Most neurosurgeons avoid combined procedures, such as shunt placement and fundoplication with gastros-
Pyloromyotomy in the Treatment of Infantile Pyloric Stenosis Several studies discuss the reported incidence of wound infection after pyloromyotomy in infants. However, the risk varies widely from less than 1 percent to 12 percent.49,50 Whether patients undergoing pyloromyotomy will benefit from prophylactic antibiotics is difficult to determine. With no entrance into the gastrointestinal system, the expected complication rate should be very low; however, because of
Pediatric Surgical Wound Infections preexisting obstruction, some authors recommend routine prophylaxis.28 A recent study by Leinwand et al51 reviewed 344 patients who underwent open pyloromyotomy. The study was designed to compare the complication rate, including surgical site infections, between the periumbilical approach and the right upper-quadrant approach. The authors reported an overall wound infection rate of 2.6 percent, which was decreased to 1.8 percent with appropriate preoperative antibiotic administration. Interestingly, the overall wound complication rate was statistically higher in the periumbilical group (6.7% v 2.8%, P ⬍ .001), but this difference was not statistically significant in those treated with prophylactic antibiotics. Although no solid data exist, laparoscopic pyloromyotomy would be expected to have a low risk of infection. If prophylaxis is given, a single preoperative dose of a first-generation cephalosporin is sufficient coverage.
Fundoplication/Gastrostomy Tube Placement Fundoplication should have a very low rate of surgical site infection, similar to that seen with pyloromyotomy, when performed without a gastrostomy tube. Gastrostomy tubes can be placed by several techniques: laparoscopically, open, and percutaneous endoscopic gastrostomy placement. The gastric flora in children requiring fundoplication and gastrostomy tube placement are variable. Wound infections cultured after fundoplication or gastrostomy tube have a more complex microbiologic profile. The most common organisms include E coli, Peptostreptococcus, Enterococcus, Bacteroides, Staphylococcus, and Candida.52 Unfortunately, among these organisms, -lactamase producers frequently were present, which may render these relatively common infections more difficult to treat.52 The risk of a surgical site infection after gastrostomy is approximately 8 percent and has been reported to be as high as 50 percent in children with malignancy or end-stage acquired immunodeficiency syndrome.53 The incidence of complications does not appear to be different at primary operation based on technique (open, laparoscopic, percutaneous endoscopic).54 Interestingly, one of the most commonly performed office procedures— exchange of a percutaneous endoscopically placed gastrostomy tube to a skin level gastrostomy—also is fraught with complications, having a 20 percent complication rate of tract disruption.55 Another study showed a 7.3 percent rate of wound infection and cellulitis after catheter replacement.56 Should the physician encounter any difficulty during this procedure, fluoroscopic confirmation of tube placement should be obtained before resuming feeds. Before fundoplication or gastrostomy is performed, particularly in a high-risk patient such as one with cancer or significant immunocompromise, a single dose of a third-generation cephalosporin should be considered. In a patient who is known or suspected to have skin/nasal colonization with methicillin-resistant S aureus, coverage should be expanded to an antibiotic that does not contain a -lactam. Antibiotic prophylaxis should not differ for patients who undergo a fundoplication, fundoplication with gastrostomy tube, or placement of a gastrostomy tube alone.
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Hernia Hernia repair in the pediatric population has a very low infection rate, cited at less than 1 percent in most studies.13 Prophylaxis should be considered only in the high-risk patient or the unusual older patient who requires insertion of mesh for repair of the hernia.57
Antibiotic Prophylaxis Based on the CDC guidelines, prophylaxis with antibiotics should be considered for clean-contaminated or contaminated cases, operations in which a foreign material is implanted, patients with heart valve disease, and patients who fall into high-risk groups.2 Despite lack of solid data supporting the use of routine antibiotic prophylaxis in neonates, most pediatric surgeons are not likely to abandon this practice unless future studies show it to be unnecessary or harmful.28 Prophylaxis should be carefully directed to the organisms most likely to cause infection. In general, for incisions involving skin and soft tissues, antibiotic coverage should be directed at gram-positive organisms. Use of an antibiotic effective against -lactamase producers should be considered when dealing with a patient who has had either longterm or frequent hospitalizations. For incisions involving the upper intestinal tract, antibiotics should be directed at gram-negative bacilli and may include coverage for anaerobes. An agent such as cefoxitin or cefotetan would provide adequate coverage. Operations that involve the appendix or colon should be preceded by administration of an agent that is effective against gram-negative bacilli and anaerobes. Again, a third-generation cephalosporin is adequate. However, if peritonitis or active infection is anticipated or encountered, antibiotic coverage should be broadened and may include an aminoglycoside coupled with metronidazole or clindamycin or, in the young adult, a fluoroquinolone coupled with metronidazole or clindamycin. When antimicrobial prophylaxis is deemed appropriate, the antibiotic should be given within 2 hours of the time of incision and redosed according to the drug’s half-life should the operation be lengthy.28,58 Many surgeons prefer to have the antibiotic dosed once the patient is in the operating suite to ensure that a long period has not passed since the antimicrobial agent was administered. For dirty, class IV, cases, antibiotic prophylaxis should not be prescribed. Instead, the patient should receive antimicrobial therapy directed against the appropriate organisms both preoperatively and postoperatively.
Conclusion Despite numerous advances in the fields of medicine, surgery, and infectious disease, surgical site infection remains a source of postoperative morbidity and contributes to increased hospital costs and the patient’s length of stay. Inappropriate use of antimicrobial therapy is suspected to contribute to bacterial resistance now frequently encountered in both the inpatient and outpatient settings through-
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out much of the United States. The current reported incidence of surgical site infection in the pediatric population is approximately 4.5 percent.13 Preoperative consideration of the patient’s risk factors for surgical site infection, including wound class as well as additional risk factors, should be taken. This consideration will allow for proper timing for administration of the antibiotic, as well as time to document in the patient’s record and notify the patient’s caretaker of the increased risk for surgical site infection and potential increased postoperative morbidity or mortality. Antibiotic prophylaxis is appropriate in class II to IV wounds as well as class I wounds that occur in high-risk patients or patients who are receiving an implantable device. For antibiotic prophylaxis to be effective, it must be dosed within 2 hours of surgery, which is best accomplished via dosing either in day surgery holding or in the operating room after induction of anesthesia.
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Pediatric Surgical Wound Infections 34. Borgbjerg BM, Gjerris F, Albeck MJ, et al: Risk of infection after cerebrospinal fluid shunt: An analysis of 884 first-time shunts. Acta Neurochir 136:1-7, 1995 35. Williams DG, Hayes J, McCool S: Shunt infections in children: Presentation and management. J Neurosci Nurs 28:155-162, 1996 36. Horgan MA, Piatt JH Jr: Shaving of the scalp may increase the rate of infection in CSF shunt surgery. Pediatr Neurosurg 26:180-184, 1997 37. Choux M, Genitori L, Land D, et al: Shunt implantation: Reducing the incidence of shunt infection. J Neurosurg 77:875880, 1992 38. Rieder MJ, Frewen TC, Del Maestro RF, et al: The effect of cephalothin prophylaxis on postoperative ventriculo-peritoneal shunt infections. CMAJ 136:935-938, 1987 39. Pittman T, Williams D, Weber TR, et al: Risk of abdominal operations in children with ventriculoperitoneal shunts. J Pediatr Surg 27:1051-1053, 1992 40. Altemeier WA: The bacterial flora of acute perforated appendicitis with peritonitis. Ann Surg 107:517-528, 1938 41. Bohnen JM, Solomkin JS, Dellinger EP, et al: Guidelines for clinical care: Anti-infective agents for intra-abdominal infection. A surgical infection society policy statement. Arch Surg 127:83-89, 1992 42. Baron EJ, Bennion R, Thompson J, et al: A microbiological comparison between acute and complicated appendicitis. Clin Infect Dis 14:227-231, 1992 43. Liberman MA, Gleason KL, Frame S, et al: Single-dose cefotetan or cefoxitin versus multiple-dose as prophylaxis in patients undergoing appendectomy for acute nonperforated appendicitis. J Am Coll Surg 180:77-80, 1995 44. Doraiswamy NV: The neutrophil count in childhood acute appendicitis. Br J Surg 64:342-344, 1977 45. Keller MS, McBride WJ, Vane DW: Management of complicated appendicitis: A rational approach based on clinical course. Arch Surg 131:261-264, 1996 46. Mosdell DM, Morris DM, Fry DE: Peritoneal cultures and antibiotic therapy in pediatric perforated appendicitis. Am J Surg 167:313-316, 1994 47. Bilik R, Burnweit C, Shandling B: Is abdominal cavity culture of any value in appendicitis? Am J Surg 175:267-270, 1998
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48. Fisher KS, Ross DS: Guidelines for therapeutic decision in incidental appendectomy. Surg Gynecol Obstet 171:95-98, 1990 49. Nour S, MacKinnon AE, Dickson JA, et al: Antibiotic prophylaxis for infantile pyloromyotomy. J R Coll Surg Edinb 41:178180, 1996 50. Hulka F, Harrison MW, Campbell TJ, et al: Complications of pyloromyotomy for infantile hypertrophic pyloric stenosis. Am J Surg 173:450-452, 1997 51. Leinwand MJ, Shaul DB, Anderson KD: The umbilical fold approach to pyloromyotomy: Is it a safe alternative to the right upper-quadrant approach? J Am Coll Surg 189:362-367, 1999 52. Brooks I: Microbiology of gastrostomy site wound infections in children. J Med Microbiol 43:221-223, 1995 53. Cappell MS, Godil A: A multicenter case-controlled study of percutaneous endoscopic gastrostomy in HIV-seropositive patients. Am J Gastroenterol 81:2059-2066, 1993 54. Moller P, Lindberg CG, Zilling T: Gastrostomy by various techniques: Evaluation of indications, outcome and complications. Scand J Gastroenterol 34:1050-1054, 1999 55. Romero R, Martinez FL, Robinson SY, et al: Complicated PEG-to-skin level gastrostomy conversions: Analysis of risk factors for tract disruption. Gastrointest Endosc 44:230-234, 1996 56. Fox VL, Abel SD, Malas S, et al: Complications following percutaneous endoscopic gastrostomy and subsequent catheter replacement in children and young adults. Gastrointest Endosc 45:64-71, 1997 57. Platt R, Zucker JR, Zaleznik DF, et al: Prophylaxis against wound infection following herniorrhaphy or breast surgery. J Infect Dis 166:556-560, 1992 58. Martin C: Antimicrobial prophylaxis in surgery. General concepts and clinical guidelines. French Study Group on Antimicrobial Prophylaxis in Surgery, French Society of Anesthesia and Intensive Care. Infect Control Hosp Epidemiol 15:463-471, 1994 59. Garner JS: CDC guideline for prevention of surgical wound infections, 1985. Infect Control 7:193-200, 1986 60. Simmons BP: Guideline for prevention of surgical wound infections. Am J Infect Control 4:133-143, 1983