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Treatment of Surgical Infections in the Ambulatory Patient
TREATMENT OF SURGICAL INFECTIONS IN THE AMBULATORY PATIENT WILLIAM A. ALTEMEIER,
M.D., F.A.C.S. * AND JEROME GIUSEFFI, M.D. t
ALTHOUGH the treatment of major surgical infections has been significantly changed by the development and use of modern antibiotic agents during the past eight years, relatively little consideration has been given to the therapy of minor surgical infections in the ambulatory patient. The repeated revaluation of therapy of surgical lesions in these patients is advisable because the care of minor surgical infections constitutes a large proportion of active surgical practice, and because the efficacy of proper treatment reflects itself significantly in the medical, economic and social affairs of a community. A patient who can safely go to and from the physician's office or dispensary for effective treatment may be considered "an ambulatory patient." Thus, the selection of patients for ambulatory treatment is more or less automatically made. In general, these patients have smaller and less severe infections which are relatively superficial in position and often well localized. Their care is attended with little or no mortality,' requires few or no assistants and can be performed in' the office or outpatient dispensary. Considerable care and vigilance, however, must be exerted to insure safety. Accurate and early diagnosis is necessary for consistently good. results. If the diagnosis is unknown and if the course runs contrary 'to that generally expected, significant deviations should be detected earlY-and hospitalization arranged when indicated. The ability to treat many varieties of surgical infections without hospitalization of the patient has many obvious advantages, including a considerable saving of money and time for the patient. It often permits him the opportunity of continuing wholly or in part his daily work and it makes accessible hospital beds for patients actually requiring them. This is of considerable importance at this time. The disadvantages of ambulatory treatment include less adequate facilities for diagnosis and treatment and the requirement of more of the physician'S time to see and care for the patient.
GENERAL CONSIDERATIONS
Principles of Treatment. The general principles involved in the effective treatment of surgical infections have remained essentially unchanged. From the Department of Surgery, College of Medicine of the University of Cincinnati, and the Cincinnati General Hospital, Cincinnati, Ohio. * Assistant Professor of Surgery, University of Cincinnati College of Medicine; Attending Surgeon, Cincinnati General, Children's and Holmes Hospitals; Clinician, Outpatient DispenBltry, Cincinnati General Hospital; Assistant Attending Surgeon, Christ and Good Samaritan Hospitals. t J.I).!!t~lJ.\ltp}." jp Surgery, University of Cincinnati College of Medicine.
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They consist of the following: (1) physiologic rest and intelligent immobilization; (2) elevation Of the involved area, (3) utilization of localized heat, and (4) early incision and drainage when suppuration is present. To these time-honored concepts has been added another, namely, (5) the utilization of the proper chemotherapeutic agent. The application of these principles varies necessarily with the type and location of the individual infection. Rest of an infected area aids in the localization of the infection and minimizes the tendency for its spread. In the ambulatory patient, immobilization of the involved area may be secured by the use of slings, splints or dressings whenever practicable. One must be aware of the disadvantages of complete, needless or excess·ive immobilization which may produce joint stiffness, muscle wasting, and functional impairment far exceeding the magnitude of the original illness. Accordingly, it is important to apply the concept of rest and immobilization in their proper perspective to their total advantage in the control of the disease process, and to discontInue them when these advantages are outweighed by detrimental effects. Elevation of an infected part is a therapeutic measure which may be of importance in minimizing pain and reducing swelling. If edema is present, the process of healing and repair is greatly retarded or inhibited. Elevation of the infected and edematous part to a level slightly above that of the heart may be very effective. The application of local heat for the purpose of inducing hyperemia and increasing the local defep.se mechanism is generally accepted. Local heat may be applied in one of several ways. It has been customary practice in many localities to use hot wet dressings or fomentations for this purpose. This therapy is particularly valuable in dealing with infected areas containing nonviable or sloughing tissue, which must be separated from the wound before satisfactory cleansing can be obtained. However, in instances of cellulitis or lymphangitis, application of a dry, bulky dressing insulates the part and utilizes the local heat generated in the infected area, thus securing increased local temperature without extensive maceration of the skin. If wet dressings are used over open infected wounds, the solutions may act as vehicles for the dissemination of bacteria in wound exudates, and may cause maceration and infection of the surrounding skin. For these reasons, we are confining the use of wet dressings to selected cases where the rapid separation of slough is indicated. Particular care in the preparation of skin whenever any dressing is to be applied or if incision and drainage is to be performed is important. The surrounding skin is carefully shaved over a wide area after which it is cleansed thoroughly with soap, water, alcohol and ether, and then painted with a suitable antiseptic. The importance of meticulous care in the preparation of skin and the application of a good functional
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SURGICAL INFECTIONS IN AMBULATORY PATIENT
dressing are indications of the ability of the surgeon and are reflected in a decreased morbidity and increased comfort of the patient. Drainage of developing abscesses by adequate incision is a fundamental objective of surgical treatment and it is as important now as it was before the advent of chemotherapy. The sooner the presence of suppuration is recognized and proper drainage is instituted, the speedier is the recovery. The selection of the proper antibiotic agent is of considerable importance in the rapid control of the infection and healing. A presumptive diagnosis made as to the probable infecting organism is usually possible from the clinical characteristics of the minor infection. When exudates are present and can be obtained by incision or drainage or aspiration, they may be examined microscopically by preparing Gram stains of smears. In resistant infections, cultures and bacterial sensitivity tests to the various TABLE 1 DOSAGE AND ROUTE OF ADMINISTRATION OF ANTIBIOTIC AGENTS --
Route of Administration
Average Adult Dose
Interval Between Doses HOUTS
1. Penicillin G Aqueous ....... Intramuscular 2. Combination, Penicillin G Aqueous and Procaine Penicillin ................ Intramuscular
3. 4. 5. 6.
Chloromycetin ............. Aureomycin ................ Terramycin ................ Penicillin ..................
Oral Oral Oral Oral
100,000-500,000 units
12-24
100,000 units 300,000 units 500 mg. 500 mg. 500 mg. 200,000 units
24 24 4-6 4-6 4-6 3-4
antibiotic agents should be done when possible to aid in the selection of a suitable and effective antibiotic agent. The antibiotic agents used for the chemotherapy of minor surgical infections are usually penicillin, chloromycetin, aureomycin, terramycin and streptomycin. The average adult dosage of each that may be used and the interval between doses is indicated in Table 1. The topical use of antibiotics in the treatment of infected wounds may be effective but their use should be reserved for specific indications. Indiscriminate local use of antibiotics increases the incidence of hypersensitivity of the individual to that antibiotic and increases the incidence of super or secondary infections by resistant h.acteria. TnEATMENT OF SURGICAL INFECTIONS
Minor surgical infections may be acute or chronic, localized, progressive or invasive, primary or secondary, monomicrobic or polymicrobic,
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WILLIAM A. ALTEMEIER AND JEROME GIUSEFFI
specific or nonspecific, for purposes of classification. The infections to be discussed here are nonspecific. Wound Infections and Abscesses. When a wound becomes infected, inflammation with destruction of tissue occurs and healing is retarded or inhibited. The great majority of ~ounds which become infected do so either because of lack of treatment or because some principle of surgical care has been violated. In the majority of instances, the offending organism is the hemolytic Staphylococcus aureus and the hemolytic streptococcus, the former being more prevalent than the latter. A mixed bacterial flora consisting of both gram-negative and gram-positive bacteria may also occur in surgical wounds. The infection may either be localized to the immediate confines of the wound or it may become invasive with cellulitis, lymphangitis or bacteremia developing.
A
B
Fig. 356. A, Appearance of infected wound immediately after sutures have been removed. The wound has been opened completely, gently irrigated with saline, and penicillin therapy started. B, Appearance six days following onset of therapy. Granulations are clean and healthy. The wound is contracting and healing in.
Infected wounds are treated promptly by removal of sutures, adequate opening of the wound with the establishment of free drainage, and the systemic use of antibiotics (Fig. 356). In mixed infections, the establishment of drainage is particularly important to prevent extension of the necrotizing process. Sutured wounds showing signs of abscess formation should be reopened by removal of sutures and spreading of the edges with a hemostat at the point of maximum pain, swelling or fluctuation. The opening is then enlarged adequately to the size of the abscess cavity, which is irrigated gently with warm physiologic saline and filled with loosely applied fine dry mesh gauze in layers to insure external drainage. A dry dressing is then applied to prevent secondary infection and to provide immobilization, rest and elevation of the infected part. The control of
SURGICAL INFECTIONS IN AMBULATORY PATIENT
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purulent exudate arising from the wound surface is very important. These exudates contain enzymes which are capable of producing maceration, further digestion of tissues, or toxic absorption if trapped and held in close approximation to the wound surfaces. Gauze impregnated with petrolatum or greasy ointments may produce these results when applied to infected tissues. In addition, all necrotic tissues or foreign bodies should be removed under the protective screen of systemic antibiotic therapy after the invasive qualities of the infection have been overcome. Removal is best effected by sharp dissection, being careful not to produce bleeding. Enzymatic removal of necrotic slough with solutions of crystalline trypsin or collagenase is being done experimentally. In the treatment of infected wounds, antibiotic therapy is started at once. Bacteriological diagnosis by smear and culture is valuable for the selection of the antibiotic agent whenever possible. Penicillin is the agent of choice in most hemolytic staphylococcal and streptococcal infections. In many staphylococcal infections, however, the bacteria have been resistant to penicillin in our experience, and one of the other antibiotics such as chloromycetin, aureomycin or terramycin has been used effectively. These latter agents or a combinationo f penicillin and streptomycin are usually of benefit in the management of mixed infections. Iodine or other antiseptics should not be applied to the wound surfaces, and antibiotics should be applied topically only under certain indications. Careful dressing technic minimizes secondary infections. Dressings are changed every one to seven days, depending upon the condition of the wound, the type of infection, and the progress of healing. Cellulitis. Cellulitis is a diffuse inflammation of the skin and subcutaneous tissues due to the invasion of pyogenic bacteria. It usually arises from an infected superficial. wound such as laceration, infected ulcer, callus, vesicle, or invisible puncture wound produced by a needle or insect bite. The etiologic agents are either the hemolytic streptococcus or the hemolytic staphylococcus. The diagnosis is made on the basis of the diffuse redness, increased local heat, slight pain and tenderness which is limited to the superficial aspects of the area, and soft edema of the involved skin and subcutaneous tissues. Great care must be exercised in differentiating pyogenic cellulitis from conditions such as hemolytic streptococcal gangrene, crepitant clostridial cellulitis, nonclostridial cellulitis, and gas gangrene lesions, whic~ are not to be treated as minor infections in ambulatory patients. If extensive necrosis of the overlying skin, suppuration of subcutaneous tissues, and undermining of the margins occur in neglected cases of cellulitis, the patient should be hospitalized for treatment. Surgical intervention in the presence of cellulitis is delayed unless and until abscess formation occurs' and requires drainage. Primary treatment consists of rest, elevation of the part if an extremity is involved, applica-
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WILLIAM A. ALTEMEIER AND JEROME GIUSEFFI
tion of local heat, and chemotherapy. Antibiotic therapy usually results in the rapid control of the infection, often within twenty-four hours. The earlier that chemotherapy is started, while the infection is in the diffuse inflammatory phase, the greater are the chances of spontaneous resolution of the process without development of cutaneous gangrene or localized abscess formation. Penicillin is usually the drug of choice, although chloromycetin, terramycin or aureomycin may be used effectively. Lymphangitis. Acute lymphangitis is an infection with acute onset which arises from an infected wound or other localized infection, and spreads rapidly along the regional lymphatics. Most frequently caused by the hemolytic streptococcus, it represents an invasive spreading infection with little tendency to localize or produce tissue necrosis. It is often encountered in the upper extremity in persons whose occupation requires exposure of the hands to instruments soiled by infected material. A hemorrhagic vesicle may develop at the portal of entry and red lines of spreading infection along the superficial lymphatics of the extremity may become visible, swollen and tender. Chills, fever and irritability are usually present. Conservative treatment is indicated and surgical manipulation or incision, in the presence of the invasive infection, should be avoided. Rest, elevation of the part, local application of heat, temporary bed rest, immobilization, and systemically administered antibiotic therapy are indicated. Penicillin is usually very effective. Either 100,000 units of aqueous penicillin G may be given every eight to twelve hours intramuscularly or 1 cc. of a preparation containing 100,000 units of aqueous penicillin and 300,000 units of procaine penicillin may be given every twelve to twenty-four hours intramuscularly. Chloromycetin, terramycin and aureomycin are also efficacious when given in ordinary adult dosage. Under treatment continued for several days, the lymphangitis will usually subside rapidly within twenty-four to forty-eight hours without the development of localized abscesses. However, residual subcutaneous abscesses or suppurative adenitis may occur and require incision and drainage. AcuteLymphadenitis. Acute lymphadenitis is an inflammatory process of the regional lymph nodes due to extension of the infection from a neighboring focus. The primary site of infection, such as tonsillitis, an infected wound, carbuncle, area of cellulitis or other similar lesion is usually demonstrable. T4e adenitis either appears at the height of the infection or within seven to ten days, and· appears most frequently in the neck (Fig. 357), axilla or groin. The infection may either subside or proceed to necrosis and abscess formation. The treatment of lymphadenitis is directed primarily toward the eradication of the original portal of infection and secondarily toward
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1265
the area of infection in the lymph nodes. Management of the primary lesion depends upon its nature and consists usually of conservative measures, including rest, elevation, local application of heat, and antibiotic therapy. When suppuration occurs, incision and drainage are necessary after the invasive qualities of the infection have been overcome. Penicillin is usually the antibiotic agent of choice, with aureomycin, chloromycetin and terramycin as alternates. Abscesses. Superficial abscesses are the residual complications of infections such as lymphadenitis, lymphangitis, cellulitis, infected wounds and suppurative thrombophlebitis.
Fig. 357. Example of cervical adenitis which has developed a localized abscess despite penicillin therapy, and will now require incision and drainage.
As soon as localization and abscess formation have occurred, adequate incision and drainage is the only satisfactory treatment. The direction of the incision should be chosen carefully to prevent injury to important adjacent structures and to avoid disabling or disfiguring scars. Accurate anatomic knowledge of the area is required to obtain adequate drainage without impairment of function in deep abscesses. Mter incision of the abscess, its cavity is treated as that of an infected wound as previously described. Similar antibiotic therapy is also indicated. Furuncles. Furuncles or boils are localized staphylococcic infections of the skin and subcutaneous tissues, originating as an infection of a hair follicle or sebaceous gland. An area of induration with central necrosis and pus formation is the essential pathological lesion. It may occur any-
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WILLIAM A. ALTEMEIER AND JEROME GIUSEFFI
where on the surface of the body, but usually is found where friction or irritation is most common, such as the back of the neck, arms, axillae, hands and wrist, back and face (Fig. 358). It continues to extend more deeply to produce a larger area of swelling and cellulitis. Secondary infection of adjacent or neighboring hair follicles with a series of furuncles following one another may occur. It is particularly important to prepare the skin surrounding the area of the furuncle by thorough cleansing with soap water, alcohol and ether, and then painting with a suitable antiseptic. Every effort is made to keep the area dry to minimize spread of the infection to adjacent hair follicles.
B A Fig. 358. A, Furuncle of the upper lip. The local lesion is treated very conservatively, avoiding trauma or meddlesome surgery because of dangers associated with possible extension to cavernous sinus. B, Appearance five days later following penicillin therapy.
Soap containing G-ll, "Germa-medica," may be used for control of secondary infections. If suppuration occurs, drainage through an incision is performed. Chemotherapy with penicillin administered systemically is of great value in controlling the individual infection and in preventing secondary infections. Excessive amounts of carbohydrates in the diet should be discouraged. Carbuncles. A carbuncle is essentially a spreading and necrotizing staphylococcal infection of the deeper layers of the skin and subcutaneous tissue which produces local necrosis and liquefaction. Its association with diabetes mellitus is well known. Antibiotic therapy has revolutionized the treatment of carbuncles and has permitted a large number of patients with them to be managed while ambulatory in conjunction with rest, local application of heat, cleanly
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care of surrounding skin, adequate hydration, and supportive treatment (Fig. 359). Penicillin is obviously the chemotherapeutic agent of choice. When the infecting organism is resistant to penicillin, other antibiotics such as aureomycin, chloromycetin, terramycin or streptomycin may • be used effectively. Sulfonamide therapy has been disappointing because of the natural resistance of the hemolytic Staphylococcus aureus and should not be used. Penicillin should be given early, in sufficient dosage, and for a period of at least seven to ten days for control of the local and general invasive manifestations of infection.
A B Fig. 359. Showing spontaneous healing of a carbuncle in a diabetic female, aged 43, during penicillin therapy. A, Appearance of carbuncle at start of penicillin treatment. B, Disappearance of the carbuncle and almost complete healing in nine days.
For ambulatory patients, penicillin therapy may be given as follows: 1. Crystalline penicillin G in dosage of 200,000 to 500,000 units intramuscularly every twelve hours. 2. Mixture containing 300,000 units of procaine penicillin and 100,000 units of aqueous penicillin G per cubic centimeter intramuscularly every twelve to twenty-four hours. 3. Procaine penicillin, 300,000 units intramuscularly every twentyfour hours. The marked effect of penicillin in the management of carbuncles is clearly shown in a group of 100 consecutive cases which were treated between February 1944 and February 1949. Penicillin therapy was ~ollowed by control of the invasive manifestations of infection within
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WILLIAM A. ALTEMEIER AND JEROME GIUSEFFI
forty-eight to seventy-two hours followed by complete and spontaneous resolution in 41 per cent of the cases, by partial resolution with centralized necrosis in 26 per cent, with partial resolution and abscess formation in 28 per cent, and by failure in 4 per cent of the cases. Death occurred in one case from a secondary or superinfection of the blood stream by a bacillus of the paracolon group. Complete excision of the lesion in order to control this infection was necessary in only four cases, and more limited surgical procedures are recommended when indicated consisting of incision and drainage of abscess occurring during therapy and cruciate incision for the removal of necrotic tissue (Fig. 360). Failure to control
A
B
Fig. 360. A, Partial resolution of a carbuncle with residual necrosis during systemic penicillin treatment. B, Cruciate incision with removal of necrotic center facilitated rapid healing.
the local infection, uncontrolled diabetes, and blood stream infection are indications for immediate hospitalization of the patient. Infected Sebaceous Cysts. Sebaceous cysts, found most frequently on the scalp, face, ear and neck, are frequently complicated by infection. This causes redness, pain, tenderness, rapid enlargement of the area, and fluctuation in addition to the usual disfigurement. The increase in swelling is due to edema and formation of pus. When the cyst is acutely inflamed, simple incision and dFainage is indicated. The abscess cavity is then irrigated gently with physiological saline, filled loosely with dry fine mesh gauze, and covered with a dry dressing. Since the infecting bacterium is usually the staphylococcus or streptococcus, systemic antibiotic therapy when used should consist of penicillin or chloromycetin, aureomycin, or terramycin.
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Attempts to dissect out the cyst wall should not be made in the presence of infection because of the possibilities of spreading the infection, of incompletely removing the epithelial lining, and of increasing the resultant scar. Occasionally, infection may result in a cure of the cyst after incision and drainage, but usually radical excision is necessary in six or more weeks when the infection has been completely controiled. Human Bite Infections. Although human bite infections are usually sufficiently serious to require immediate hospitalization and treatment, modern antibiotic therapy has had such a marked effect on this condition that it is now possible to treat some of them in ambulatory patients. The infection usually occurs when a human being voluntarily bites another or strikes a blow, his hand thereby being punctured by the tooth of the intended victim. Since the wound is made with a relatively dull object, contusion of the deeper tissues occurs which supports the growth of a mixed bacterial flora usually consisting of such bacteria as the aerobic nonhemolytic streptococcus, anaerobic streptococcus, B. melaninogenicum, spirochetes, staphylococcus and actinomyces. We have treated the vast majority of fresh human bites without joint involvement on an ambulatory status. The wound is thoroughly and completely debrided, after which it is left open and packed gently with zinc peroxide ointment and the hand immobilized on an aluminum splint in the position of function. In addition, the patient is then started on penicillin, receiving generally 100,000 units of the aqueous penicillin G and 300,000 units of procaine penicillin every twenty-four hours for seventy-two to ninety-six hours. The patient is observed carefully during this period at daily intervals. This method of treatment has been eminently satisfactory. When fresh human bite wounds are inadequately treated, inflammation appears within twenty-four to forty-eight hours as a spreading cellulitis. The part becomes swollen, red, painful, and temporarily useless. The granulation tissue developing in the wound becomes gray, edematous and shaggy, and it exudes a thick, foul-smelling purulent fluid. Progressive necrosis of areolar and collagenous tissue follows. After infection has become established, decompression of the infected area and the tissue planes by surgical incision followed by application of zinc peroxide dressing incorporating a splint for immobilization is indicated. The early use of one of the antibiotics in adequate dosage, particularly penicillin, is a particularly valuable adjunct to surgery in the control of this lesion. Infected Burns. Infection is a common complication of cutaneous thermal burns. Only patients with infected burns of limited area should be treated while ambulatory. Some of the most important factors in the incidence of infection are the depth or degree of the burn and the amount of cutaneous slough
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WILLIAM A. ALTEMEIER AND JEROME GIUSEFFI
produced. It is important to remember that all burn surfaces are contaminated with bacteria when seen by the physician, that the presence of slough invites the growth of saprophytic and virulent bacteria, and that it is practically impossible to sterilize viable skin. Infections developing in burns may be acute or chronic, and nonspecific or specific. Acute nonspecific infections may occur primarily during the first three to four days due to the virulence of the hemolytic Staphylococcus aureus or hemolytic streptococcus. The process may be limited to the slough, but more frequently it invades the adjacent viable tissues or circulation. It may also occur as a secondary infection produced by a mixture of bacteria including the hemolytic staphylococcus, hemolytic streptococcus, or gram-negative bacilli. Acute specific infections may include tetanus or gas gangrene, but these will not be considered here since hospitalization is a necessary requirement for modern treatment. Chronic infections are particularly difficult to manage and usually occur as chronically infected granulating surfaces or recurrent ulcerations in 'previously healed areas. During the acute stage, control of the invasive manifestations of the infection is best effected by rest, adequate systemic chemotherapy with penicillin, or one of the other antibiotics as indicated, and cleanly dressing care. Later treatment is largely directed toward early removal of the slough in conjunction with systemic antibiotic treatment followed by the application of skin grafts if necessary. In chronically infected granulating burn wounds, the problem may be difficult. Mixed infections have become well established and the B. pyocyaneus is commonly present. Treatment consists of rest, elevation and immobilization of the part, application of compression dressings to flatten the exuberant granulations, and antibiotic therapy. The latter varies with the type and susceptibility of the infecting bacteria. Topical applications of antibiotics suspended in' water-soluble and greaseless bases may be of considerable value. Dressings are changed everyone to four days until the granulations are clean and will support the growth of regenerating or grafted skin. SUMMARY
A considerable proportion of active surgical practice is concerned with the management of minor established infections. These may be treated effectively while the patient is ambulatory at a great saving in time and money to the patient. Hospital beds are likewise saved for more seriously ill patients who need them. The introduction and use of the modern antibiotic agents as adjuncts to established therapeutic principles has significantly benefited the care of patients with minor infections.
M.D., F.A.C.S. * AND JEROME GIUSEFFI, M.D. t
ALTHOUGH the treatment of major surgical infections has been significantly changed by the development and use of modern antibiotic agents during the past eight years, relatively little consideration has been given to the therapy of minor surgical infections in the ambulatory patient. The repeated revaluation of therapy of surgical lesions in these patients is advisable because the care of minor surgical infections constitutes a large proportion of active surgical practice, and because the efficacy of proper treatment reflects itself significantly in the medical, economic and social affairs of a community. A patient who can safely go to and from the physician's office or dispensary for effective treatment may be considered "an ambulatory patient." Thus, the selection of patients for ambulatory treatment is more or less automatically made. In general, these patients have smaller and less severe infections which are relatively superficial in position and often well localized. Their care is attended with little or no mortality,' requires few or no assistants and can be performed in' the office or outpatient dispensary. Considerable care and vigilance, however, must be exerted to insure safety. Accurate and early diagnosis is necessary for consistently good. results. If the diagnosis is unknown and if the course runs contrary 'to that generally expected, significant deviations should be detected earlY-and hospitalization arranged when indicated. The ability to treat many varieties of surgical infections without hospitalization of the patient has many obvious advantages, including a considerable saving of money and time for the patient. It often permits him the opportunity of continuing wholly or in part his daily work and it makes accessible hospital beds for patients actually requiring them. This is of considerable importance at this time. The disadvantages of ambulatory treatment include less adequate facilities for diagnosis and treatment and the requirement of more of the physician'S time to see and care for the patient.
GENERAL CONSIDERATIONS
Principles of Treatment. The general principles involved in the effective treatment of surgical infections have remained essentially unchanged. From the Department of Surgery, College of Medicine of the University of Cincinnati, and the Cincinnati General Hospital, Cincinnati, Ohio. * Assistant Professor of Surgery, University of Cincinnati College of Medicine; Attending Surgeon, Cincinnati General, Children's and Holmes Hospitals; Clinician, Outpatient DispenBltry, Cincinnati General Hospital; Assistant Attending Surgeon, Christ and Good Samaritan Hospitals. t J.I).!!t~lJ.\ltp}." jp Surgery, University of Cincinnati College of Medicine.
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WILLIAM A. ALTEMEIER AND JEROME GIUSEFFI
They consist of the following: (1) physiologic rest and intelligent immobilization; (2) elevation Of the involved area, (3) utilization of localized heat, and (4) early incision and drainage when suppuration is present. To these time-honored concepts has been added another, namely, (5) the utilization of the proper chemotherapeutic agent. The application of these principles varies necessarily with the type and location of the individual infection. Rest of an infected area aids in the localization of the infection and minimizes the tendency for its spread. In the ambulatory patient, immobilization of the involved area may be secured by the use of slings, splints or dressings whenever practicable. One must be aware of the disadvantages of complete, needless or excess·ive immobilization which may produce joint stiffness, muscle wasting, and functional impairment far exceeding the magnitude of the original illness. Accordingly, it is important to apply the concept of rest and immobilization in their proper perspective to their total advantage in the control of the disease process, and to discontInue them when these advantages are outweighed by detrimental effects. Elevation of an infected part is a therapeutic measure which may be of importance in minimizing pain and reducing swelling. If edema is present, the process of healing and repair is greatly retarded or inhibited. Elevation of the infected and edematous part to a level slightly above that of the heart may be very effective. The application of local heat for the purpose of inducing hyperemia and increasing the local defep.se mechanism is generally accepted. Local heat may be applied in one of several ways. It has been customary practice in many localities to use hot wet dressings or fomentations for this purpose. This therapy is particularly valuable in dealing with infected areas containing nonviable or sloughing tissue, which must be separated from the wound before satisfactory cleansing can be obtained. However, in instances of cellulitis or lymphangitis, application of a dry, bulky dressing insulates the part and utilizes the local heat generated in the infected area, thus securing increased local temperature without extensive maceration of the skin. If wet dressings are used over open infected wounds, the solutions may act as vehicles for the dissemination of bacteria in wound exudates, and may cause maceration and infection of the surrounding skin. For these reasons, we are confining the use of wet dressings to selected cases where the rapid separation of slough is indicated. Particular care in the preparation of skin whenever any dressing is to be applied or if incision and drainage is to be performed is important. The surrounding skin is carefully shaved over a wide area after which it is cleansed thoroughly with soap, water, alcohol and ether, and then painted with a suitable antiseptic. The importance of meticulous care in the preparation of skin and the application of a good functional
1261
SURGICAL INFECTIONS IN AMBULATORY PATIENT
dressing are indications of the ability of the surgeon and are reflected in a decreased morbidity and increased comfort of the patient. Drainage of developing abscesses by adequate incision is a fundamental objective of surgical treatment and it is as important now as it was before the advent of chemotherapy. The sooner the presence of suppuration is recognized and proper drainage is instituted, the speedier is the recovery. The selection of the proper antibiotic agent is of considerable importance in the rapid control of the infection and healing. A presumptive diagnosis made as to the probable infecting organism is usually possible from the clinical characteristics of the minor infection. When exudates are present and can be obtained by incision or drainage or aspiration, they may be examined microscopically by preparing Gram stains of smears. In resistant infections, cultures and bacterial sensitivity tests to the various TABLE 1 DOSAGE AND ROUTE OF ADMINISTRATION OF ANTIBIOTIC AGENTS --
Route of Administration
Average Adult Dose
Interval Between Doses HOUTS
1. Penicillin G Aqueous ....... Intramuscular 2. Combination, Penicillin G Aqueous and Procaine Penicillin ................ Intramuscular
3. 4. 5. 6.
Chloromycetin ............. Aureomycin ................ Terramycin ................ Penicillin ..................
Oral Oral Oral Oral
100,000-500,000 units
12-24
100,000 units 300,000 units 500 mg. 500 mg. 500 mg. 200,000 units
24 24 4-6 4-6 4-6 3-4
antibiotic agents should be done when possible to aid in the selection of a suitable and effective antibiotic agent. The antibiotic agents used for the chemotherapy of minor surgical infections are usually penicillin, chloromycetin, aureomycin, terramycin and streptomycin. The average adult dosage of each that may be used and the interval between doses is indicated in Table 1. The topical use of antibiotics in the treatment of infected wounds may be effective but their use should be reserved for specific indications. Indiscriminate local use of antibiotics increases the incidence of hypersensitivity of the individual to that antibiotic and increases the incidence of super or secondary infections by resistant h.acteria. TnEATMENT OF SURGICAL INFECTIONS
Minor surgical infections may be acute or chronic, localized, progressive or invasive, primary or secondary, monomicrobic or polymicrobic,
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WILLIAM A. ALTEMEIER AND JEROME GIUSEFFI
specific or nonspecific, for purposes of classification. The infections to be discussed here are nonspecific. Wound Infections and Abscesses. When a wound becomes infected, inflammation with destruction of tissue occurs and healing is retarded or inhibited. The great majority of ~ounds which become infected do so either because of lack of treatment or because some principle of surgical care has been violated. In the majority of instances, the offending organism is the hemolytic Staphylococcus aureus and the hemolytic streptococcus, the former being more prevalent than the latter. A mixed bacterial flora consisting of both gram-negative and gram-positive bacteria may also occur in surgical wounds. The infection may either be localized to the immediate confines of the wound or it may become invasive with cellulitis, lymphangitis or bacteremia developing.
A
B
Fig. 356. A, Appearance of infected wound immediately after sutures have been removed. The wound has been opened completely, gently irrigated with saline, and penicillin therapy started. B, Appearance six days following onset of therapy. Granulations are clean and healthy. The wound is contracting and healing in.
Infected wounds are treated promptly by removal of sutures, adequate opening of the wound with the establishment of free drainage, and the systemic use of antibiotics (Fig. 356). In mixed infections, the establishment of drainage is particularly important to prevent extension of the necrotizing process. Sutured wounds showing signs of abscess formation should be reopened by removal of sutures and spreading of the edges with a hemostat at the point of maximum pain, swelling or fluctuation. The opening is then enlarged adequately to the size of the abscess cavity, which is irrigated gently with warm physiologic saline and filled with loosely applied fine dry mesh gauze in layers to insure external drainage. A dry dressing is then applied to prevent secondary infection and to provide immobilization, rest and elevation of the infected part. The control of
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purulent exudate arising from the wound surface is very important. These exudates contain enzymes which are capable of producing maceration, further digestion of tissues, or toxic absorption if trapped and held in close approximation to the wound surfaces. Gauze impregnated with petrolatum or greasy ointments may produce these results when applied to infected tissues. In addition, all necrotic tissues or foreign bodies should be removed under the protective screen of systemic antibiotic therapy after the invasive qualities of the infection have been overcome. Removal is best effected by sharp dissection, being careful not to produce bleeding. Enzymatic removal of necrotic slough with solutions of crystalline trypsin or collagenase is being done experimentally. In the treatment of infected wounds, antibiotic therapy is started at once. Bacteriological diagnosis by smear and culture is valuable for the selection of the antibiotic agent whenever possible. Penicillin is the agent of choice in most hemolytic staphylococcal and streptococcal infections. In many staphylococcal infections, however, the bacteria have been resistant to penicillin in our experience, and one of the other antibiotics such as chloromycetin, aureomycin or terramycin has been used effectively. These latter agents or a combinationo f penicillin and streptomycin are usually of benefit in the management of mixed infections. Iodine or other antiseptics should not be applied to the wound surfaces, and antibiotics should be applied topically only under certain indications. Careful dressing technic minimizes secondary infections. Dressings are changed every one to seven days, depending upon the condition of the wound, the type of infection, and the progress of healing. Cellulitis. Cellulitis is a diffuse inflammation of the skin and subcutaneous tissues due to the invasion of pyogenic bacteria. It usually arises from an infected superficial. wound such as laceration, infected ulcer, callus, vesicle, or invisible puncture wound produced by a needle or insect bite. The etiologic agents are either the hemolytic streptococcus or the hemolytic staphylococcus. The diagnosis is made on the basis of the diffuse redness, increased local heat, slight pain and tenderness which is limited to the superficial aspects of the area, and soft edema of the involved skin and subcutaneous tissues. Great care must be exercised in differentiating pyogenic cellulitis from conditions such as hemolytic streptococcal gangrene, crepitant clostridial cellulitis, nonclostridial cellulitis, and gas gangrene lesions, whic~ are not to be treated as minor infections in ambulatory patients. If extensive necrosis of the overlying skin, suppuration of subcutaneous tissues, and undermining of the margins occur in neglected cases of cellulitis, the patient should be hospitalized for treatment. Surgical intervention in the presence of cellulitis is delayed unless and until abscess formation occurs' and requires drainage. Primary treatment consists of rest, elevation of the part if an extremity is involved, applica-
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tion of local heat, and chemotherapy. Antibiotic therapy usually results in the rapid control of the infection, often within twenty-four hours. The earlier that chemotherapy is started, while the infection is in the diffuse inflammatory phase, the greater are the chances of spontaneous resolution of the process without development of cutaneous gangrene or localized abscess formation. Penicillin is usually the drug of choice, although chloromycetin, terramycin or aureomycin may be used effectively. Lymphangitis. Acute lymphangitis is an infection with acute onset which arises from an infected wound or other localized infection, and spreads rapidly along the regional lymphatics. Most frequently caused by the hemolytic streptococcus, it represents an invasive spreading infection with little tendency to localize or produce tissue necrosis. It is often encountered in the upper extremity in persons whose occupation requires exposure of the hands to instruments soiled by infected material. A hemorrhagic vesicle may develop at the portal of entry and red lines of spreading infection along the superficial lymphatics of the extremity may become visible, swollen and tender. Chills, fever and irritability are usually present. Conservative treatment is indicated and surgical manipulation or incision, in the presence of the invasive infection, should be avoided. Rest, elevation of the part, local application of heat, temporary bed rest, immobilization, and systemically administered antibiotic therapy are indicated. Penicillin is usually very effective. Either 100,000 units of aqueous penicillin G may be given every eight to twelve hours intramuscularly or 1 cc. of a preparation containing 100,000 units of aqueous penicillin and 300,000 units of procaine penicillin may be given every twelve to twenty-four hours intramuscularly. Chloromycetin, terramycin and aureomycin are also efficacious when given in ordinary adult dosage. Under treatment continued for several days, the lymphangitis will usually subside rapidly within twenty-four to forty-eight hours without the development of localized abscesses. However, residual subcutaneous abscesses or suppurative adenitis may occur and require incision and drainage. AcuteLymphadenitis. Acute lymphadenitis is an inflammatory process of the regional lymph nodes due to extension of the infection from a neighboring focus. The primary site of infection, such as tonsillitis, an infected wound, carbuncle, area of cellulitis or other similar lesion is usually demonstrable. T4e adenitis either appears at the height of the infection or within seven to ten days, and· appears most frequently in the neck (Fig. 357), axilla or groin. The infection may either subside or proceed to necrosis and abscess formation. The treatment of lymphadenitis is directed primarily toward the eradication of the original portal of infection and secondarily toward
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the area of infection in the lymph nodes. Management of the primary lesion depends upon its nature and consists usually of conservative measures, including rest, elevation, local application of heat, and antibiotic therapy. When suppuration occurs, incision and drainage are necessary after the invasive qualities of the infection have been overcome. Penicillin is usually the antibiotic agent of choice, with aureomycin, chloromycetin and terramycin as alternates. Abscesses. Superficial abscesses are the residual complications of infections such as lymphadenitis, lymphangitis, cellulitis, infected wounds and suppurative thrombophlebitis.
Fig. 357. Example of cervical adenitis which has developed a localized abscess despite penicillin therapy, and will now require incision and drainage.
As soon as localization and abscess formation have occurred, adequate incision and drainage is the only satisfactory treatment. The direction of the incision should be chosen carefully to prevent injury to important adjacent structures and to avoid disabling or disfiguring scars. Accurate anatomic knowledge of the area is required to obtain adequate drainage without impairment of function in deep abscesses. Mter incision of the abscess, its cavity is treated as that of an infected wound as previously described. Similar antibiotic therapy is also indicated. Furuncles. Furuncles or boils are localized staphylococcic infections of the skin and subcutaneous tissues, originating as an infection of a hair follicle or sebaceous gland. An area of induration with central necrosis and pus formation is the essential pathological lesion. It may occur any-
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where on the surface of the body, but usually is found where friction or irritation is most common, such as the back of the neck, arms, axillae, hands and wrist, back and face (Fig. 358). It continues to extend more deeply to produce a larger area of swelling and cellulitis. Secondary infection of adjacent or neighboring hair follicles with a series of furuncles following one another may occur. It is particularly important to prepare the skin surrounding the area of the furuncle by thorough cleansing with soap water, alcohol and ether, and then painting with a suitable antiseptic. Every effort is made to keep the area dry to minimize spread of the infection to adjacent hair follicles.
B A Fig. 358. A, Furuncle of the upper lip. The local lesion is treated very conservatively, avoiding trauma or meddlesome surgery because of dangers associated with possible extension to cavernous sinus. B, Appearance five days later following penicillin therapy.
Soap containing G-ll, "Germa-medica," may be used for control of secondary infections. If suppuration occurs, drainage through an incision is performed. Chemotherapy with penicillin administered systemically is of great value in controlling the individual infection and in preventing secondary infections. Excessive amounts of carbohydrates in the diet should be discouraged. Carbuncles. A carbuncle is essentially a spreading and necrotizing staphylococcal infection of the deeper layers of the skin and subcutaneous tissue which produces local necrosis and liquefaction. Its association with diabetes mellitus is well known. Antibiotic therapy has revolutionized the treatment of carbuncles and has permitted a large number of patients with them to be managed while ambulatory in conjunction with rest, local application of heat, cleanly
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care of surrounding skin, adequate hydration, and supportive treatment (Fig. 359). Penicillin is obviously the chemotherapeutic agent of choice. When the infecting organism is resistant to penicillin, other antibiotics such as aureomycin, chloromycetin, terramycin or streptomycin may • be used effectively. Sulfonamide therapy has been disappointing because of the natural resistance of the hemolytic Staphylococcus aureus and should not be used. Penicillin should be given early, in sufficient dosage, and for a period of at least seven to ten days for control of the local and general invasive manifestations of infection.
A B Fig. 359. Showing spontaneous healing of a carbuncle in a diabetic female, aged 43, during penicillin therapy. A, Appearance of carbuncle at start of penicillin treatment. B, Disappearance of the carbuncle and almost complete healing in nine days.
For ambulatory patients, penicillin therapy may be given as follows: 1. Crystalline penicillin G in dosage of 200,000 to 500,000 units intramuscularly every twelve hours. 2. Mixture containing 300,000 units of procaine penicillin and 100,000 units of aqueous penicillin G per cubic centimeter intramuscularly every twelve to twenty-four hours. 3. Procaine penicillin, 300,000 units intramuscularly every twentyfour hours. The marked effect of penicillin in the management of carbuncles is clearly shown in a group of 100 consecutive cases which were treated between February 1944 and February 1949. Penicillin therapy was ~ollowed by control of the invasive manifestations of infection within
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forty-eight to seventy-two hours followed by complete and spontaneous resolution in 41 per cent of the cases, by partial resolution with centralized necrosis in 26 per cent, with partial resolution and abscess formation in 28 per cent, and by failure in 4 per cent of the cases. Death occurred in one case from a secondary or superinfection of the blood stream by a bacillus of the paracolon group. Complete excision of the lesion in order to control this infection was necessary in only four cases, and more limited surgical procedures are recommended when indicated consisting of incision and drainage of abscess occurring during therapy and cruciate incision for the removal of necrotic tissue (Fig. 360). Failure to control
A
B
Fig. 360. A, Partial resolution of a carbuncle with residual necrosis during systemic penicillin treatment. B, Cruciate incision with removal of necrotic center facilitated rapid healing.
the local infection, uncontrolled diabetes, and blood stream infection are indications for immediate hospitalization of the patient. Infected Sebaceous Cysts. Sebaceous cysts, found most frequently on the scalp, face, ear and neck, are frequently complicated by infection. This causes redness, pain, tenderness, rapid enlargement of the area, and fluctuation in addition to the usual disfigurement. The increase in swelling is due to edema and formation of pus. When the cyst is acutely inflamed, simple incision and dFainage is indicated. The abscess cavity is then irrigated gently with physiological saline, filled loosely with dry fine mesh gauze, and covered with a dry dressing. Since the infecting bacterium is usually the staphylococcus or streptococcus, systemic antibiotic therapy when used should consist of penicillin or chloromycetin, aureomycin, or terramycin.
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Attempts to dissect out the cyst wall should not be made in the presence of infection because of the possibilities of spreading the infection, of incompletely removing the epithelial lining, and of increasing the resultant scar. Occasionally, infection may result in a cure of the cyst after incision and drainage, but usually radical excision is necessary in six or more weeks when the infection has been completely controiled. Human Bite Infections. Although human bite infections are usually sufficiently serious to require immediate hospitalization and treatment, modern antibiotic therapy has had such a marked effect on this condition that it is now possible to treat some of them in ambulatory patients. The infection usually occurs when a human being voluntarily bites another or strikes a blow, his hand thereby being punctured by the tooth of the intended victim. Since the wound is made with a relatively dull object, contusion of the deeper tissues occurs which supports the growth of a mixed bacterial flora usually consisting of such bacteria as the aerobic nonhemolytic streptococcus, anaerobic streptococcus, B. melaninogenicum, spirochetes, staphylococcus and actinomyces. We have treated the vast majority of fresh human bites without joint involvement on an ambulatory status. The wound is thoroughly and completely debrided, after which it is left open and packed gently with zinc peroxide ointment and the hand immobilized on an aluminum splint in the position of function. In addition, the patient is then started on penicillin, receiving generally 100,000 units of the aqueous penicillin G and 300,000 units of procaine penicillin every twenty-four hours for seventy-two to ninety-six hours. The patient is observed carefully during this period at daily intervals. This method of treatment has been eminently satisfactory. When fresh human bite wounds are inadequately treated, inflammation appears within twenty-four to forty-eight hours as a spreading cellulitis. The part becomes swollen, red, painful, and temporarily useless. The granulation tissue developing in the wound becomes gray, edematous and shaggy, and it exudes a thick, foul-smelling purulent fluid. Progressive necrosis of areolar and collagenous tissue follows. After infection has become established, decompression of the infected area and the tissue planes by surgical incision followed by application of zinc peroxide dressing incorporating a splint for immobilization is indicated. The early use of one of the antibiotics in adequate dosage, particularly penicillin, is a particularly valuable adjunct to surgery in the control of this lesion. Infected Burns. Infection is a common complication of cutaneous thermal burns. Only patients with infected burns of limited area should be treated while ambulatory. Some of the most important factors in the incidence of infection are the depth or degree of the burn and the amount of cutaneous slough
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produced. It is important to remember that all burn surfaces are contaminated with bacteria when seen by the physician, that the presence of slough invites the growth of saprophytic and virulent bacteria, and that it is practically impossible to sterilize viable skin. Infections developing in burns may be acute or chronic, and nonspecific or specific. Acute nonspecific infections may occur primarily during the first three to four days due to the virulence of the hemolytic Staphylococcus aureus or hemolytic streptococcus. The process may be limited to the slough, but more frequently it invades the adjacent viable tissues or circulation. It may also occur as a secondary infection produced by a mixture of bacteria including the hemolytic staphylococcus, hemolytic streptococcus, or gram-negative bacilli. Acute specific infections may include tetanus or gas gangrene, but these will not be considered here since hospitalization is a necessary requirement for modern treatment. Chronic infections are particularly difficult to manage and usually occur as chronically infected granulating surfaces or recurrent ulcerations in 'previously healed areas. During the acute stage, control of the invasive manifestations of the infection is best effected by rest, adequate systemic chemotherapy with penicillin, or one of the other antibiotics as indicated, and cleanly dressing care. Later treatment is largely directed toward early removal of the slough in conjunction with systemic antibiotic treatment followed by the application of skin grafts if necessary. In chronically infected granulating burn wounds, the problem may be difficult. Mixed infections have become well established and the B. pyocyaneus is commonly present. Treatment consists of rest, elevation and immobilization of the part, application of compression dressings to flatten the exuberant granulations, and antibiotic therapy. The latter varies with the type and susceptibility of the infecting bacteria. Topical applications of antibiotics suspended in' water-soluble and greaseless bases may be of considerable value. Dressings are changed everyone to four days until the granulations are clean and will support the growth of regenerating or grafted skin. SUMMARY
A considerable proportion of active surgical practice is concerned with the management of minor established infections. These may be treated effectively while the patient is ambulatory at a great saving in time and money to the patient. Hospital beds are likewise saved for more seriously ill patients who need them. The introduction and use of the modern antibiotic agents as adjuncts to established therapeutic principles has significantly benefited the care of patients with minor infections.