Wound Infection Differential Diagnoses

  • Author: Hemant Singhal, MD, MBBS, FRCSE, FRCS(C); Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Jan 6, 2012
 
 

Differential Diagnoses

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Contributor Information and Disclosures
Author

Hemant Singhal, MD, MBBS, FRCSE, FRCS(C)  Senior Lecturer, Director of Breast Service, Department of Surgery, Imperial College School of Medicine; Consultant Surgeon, Northwick Park and St Marks Hospitals, UK

Hemant Singhal, MD, MBBS, FRCSE, FRCS(C) is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada and Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Coauthor(s)

Kanchan Kaur, MBBS, MS (General Surgery), MRCS (Ed)  Consulting Breast and Oncoplastic Surgeon, Medanta, The Medicity, India

Disclosure: Nothing to disclose.

Charles Zammit, MD  Senior Specialist Registrar, Department of Surgery, Breast Unit Charing Cross Hospital of London, UK

Disclosure: Nothing to disclose.

Specialty Editor Board

Brian James Daley, MD, MBA, FACS, FCCP, CNSC  Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian James Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Amy L Friedman, MD  Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University College of Medicine, Syracuse

Amy L Friedman, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Medical Women's Association, American Society for Artificial Internal Organs, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, Association of Women Surgeons, International College of Surgeons, International Liver Transplantation Society, New York Academy of Sciences, Pennsylvania Medical Society, Philadelphia County Medical Society, Society of Critical Care Medicine, and Transplantation Society

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

References

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Wound infection due to disturbed coagulopathy. This patient has a pacemaker (visible below right clavicular space) and had previous cardiac surgery (median sternotomy wound visible) for a rheumatic mitral valve disorder, which was replaced. The patient was taking anticoagulants preoperatively. Despite converting to low-molecular weight subcutaneous heparin treatment and establishing normal coagulation studies, she developed a postoperative hematoma with subsequent wound infection. She had the hematoma evacuated and was administered antibiotic treatment as guided by microbiological results, and the wound was left to heal by secondary intention.
Abscess secondary to a subclavian line.
Definitions of surgical site infection (SSI).
Factors that affect surgical wound healing.
Table 1. Pathogens Commonly Associated with Wound Infections and Frequency of Occurrence[11]
PathogenFrequency (%)
Staphylococcus aureus20
Coagulase-negative staphylococci14
Enterococci12
Escherichia coli8
Pseudomonas aeruginosa8
Enterobacter species7
Proteus mirabilis3
Klebsiella pneumoniae3
Other streptococci3
Candida albicans3
Group D streptococci2
Other gram-positive aerobes2
Bacteroides fragilis2
Table 2: Surgical Wound Classification and Subsequent Risk of Infection (If No Antibiotics Used)[11, 16]
ClassificationDescriptionInfective Risk (%)
Clean (Class I)Uninfected operative wound



No acute inflammation



Closed primarily



Respiratory, gastrointestinal, biliary, and urinary tracts not entered



No break in aseptic technique



Closed drainage used if necessary



< 2
Clean-contaminated (Class II)Elective entry into respiratory, biliary, gastrointestinal, urinary tracts and with minimal spillage



No evidence of infection or major break in aseptic technique



Example: appendectomy



< 10
Contaminated (Class III)Nonpurulent inflammation present



Gross spillage from gastrointestinal tract



Penetrating traumatic wounds < 4 hours



Major break in aseptic technique



About 20
Dirty-infected (Class IV)Purulent inflammation present



Preoperative perforation of viscera



Penetrating traumatic wounds >4 hours



About 40
Table 3. Recommendations for Prophylactic Antibiotics as Indicated by Probable Infective Microorganism Involved[11, 22]
OperationExpected PathogensRecommended Antibiotic
Orthopedic surgery (including prosthesis insertion), cardiac surgery, neurosurgery, breast surgery, noncardiac thoracic proceduresS aureus, coagulase-negative staphylococciCefazolin 1-2 g
Appendectomy, biliary proceduresGram-negative bacilli and anaerobesCefazolin 1-2 g
Colorectal surgeryGram-negative bacilli and anaerobesCefotetan 1-2 g or cefoxitin 1-2 g plus oral neomycin 1 g and oral erythromycin 1 g (start 19 h preoperatively for 3 doses)
Gastroduodenal surgeryGram-negative bacilli and streptococciCefazolin 1-2 g
Vascular surgeryS aureus, Staphylococcusepidermidis, gram-negative bacilliCefazolin 1-2 g
Head and neck surgeryS aureus, streptococci, anaerobes and streptococci present in an oropharyngeal approachCefazolin 1-2 g
Obstetric and gynecological proceduresGram-negative bacilli, enterococci, anaerobes, group B streptococciCefazolin 1-2 g
Urology proceduresGram-negative bacilliCefazolin 1-2 g
Table 4. American Society of Anesthesiologists (ASA) Classification of Physical Status[25]
ASA ScoreCharacteristics
1Normal healthy patient
2Patient with mild systemic disease
3Patient with a severe systemic disease that limits activity but is not incapacitating
4Patient with an incapacitating systemic disease that is a constant threat to life
5Moribund patient not expected to survive 24 hours with or without operation
Table 5. Predictive Percentage of SSI Occurrence by Wound Type and Risk Index*[24]
At Risk



Index



Predictive Percentage of SSI
01.5
12.9
26.8
313.0
*Hospital Infection Control Practices Advisory Committee (HICPAC) recommendations (partial) for the prevention of SSIs, April 1999 (non–drug based)
Table 6. Data Support Recommendations
CategoryDescription
Category IAWell designed, experimental, strong; recommended (Category I*) clinical or epidemiological best practice; should be studies; adapted by all practices
Category IBSome experimental, fairly strong; recommended (Category II*) clinical or epidemiological best practice; should be studies and theoretical grounds; adapted by all practices
Category IIFewer scientific supporting data; limited to specific nosocomial (Category III*) problems
No recommendationInsufficient scientific personnel judgment for use (Category III*) supporting data
*Previous nomenclature of 1992 CDC guidelines
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