Wound Infection Workup
- Author: Hemant Singhal, MD, MBBS, FRCS(Edin), FRCSC; Chief Editor: John Geibel, MD, DSc, MSc, MA more...
The simplest, and usually the quickest, staining method involves obtaining a Gram stain for infective organisms. Staining for fungal elements can be obtained at the same time.
Most laboratories routinely will culture for both aerobic and anaerobic organisms. Fungal cultures can be requested. Isolation of single colonies allows further growth and identification of the specific organism. Sensitivity testing then follows mainly for aerobic organisms.
Other techniques include the following:
- Tests for antigens from the organism through enzyme-linked immunoassay (ELISA) or radioimmunoassay
- Detection of antibody response to the organism in the host sera
- Detection of RNA or DNA sequences or protein from the infective organism by Northern, Southern, or Western blotting, respectively
- Polymerase chain reaction (PCR) to detect small amounts of microbial DNA
Ultrasonography can be applied to the infected wound area to assess whether there is a collection for which drainage is required.
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- Table 1. Pathogens Commonly Associated with Wound Infections and Frequency of Occurrence
- Table 2: Surgical Wound Classification and Subsequent Risk of Infection (If No Antibiotics Used)[8, 10]
- Table 3. Recommendations for Prophylactic Antibiotics as Indicated by Probable Infective Microorganism Involved[8, 28]
- Table 4. Predictive Percentage of SSI Occurrence by Wound Type and Risk Index*
- Table 5. American Society of Anesthesiologists (ASA) Classification of Physical Status
- Table 6. Data Support Recommendations
|Group D streptococci||2|
|Other gram-positive aerobes||2|
|Classification||Description||Infective Risk (%)|
|Clean (Class I)||Uninfected operative wound|
No acute inflammation
Respiratory, gastrointestinal, biliary, and urinary tracts not entered
No break in aseptic technique
Closed drainage used if necessary
|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
|Contaminated (Class III)||Nonpurulent inflammation present|
Gross spillage from gastrointestinal tract
Penetrating traumatic wounds < 4 hours
Major break in aseptic technique
|Dirty-infected (Class IV)||Purulent inflammation present|
Preoperative perforation of viscera
Penetrating traumatic wounds >4 hours
|Operation||Expected Pathogens||Recommended Antibiotic|
|Orthopedic surgery (including prosthesis insertion), cardiac surgery, neurosurgery, breast surgery, noncardiac thoracic procedures||S aureus, coagulase-negative staphylococci||Cefazolin 1-2 g|
|Appendectomy, biliary procedures||Gram-negative bacilli and anaerobes||Cefazolin 1-2 g|
|Colorectal surgery||Gram-negative bacilli and anaerobes||Cefotetan 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 surgery||Gram-negative bacilli and streptococci||Cefazolin 1-2 g|
|Vascular surgery||S aureus, Staphylococcusepidermidis, gram-negative bacilli||Cefazolin 1-2 g|
|Head and neck surgery||S aureus, streptococci, anaerobes and streptococci present in an oropharyngeal approach||Cefazolin 1-2 g|
|Obstetric and gynecological procedures||Gram-negative bacilli, enterococci, anaerobes, group B streptococci||Cefazolin 1-2 g|
|Urology procedures||Gram-negative bacilli||Cefazolin 1-2 g|
|Predictive Percentage of SSI|
|*Hospital Infection Control Practices Advisory Committee (HICPAC) recommendations (partial) for the prevention of SSIs, April 1999 (non–drug based)|
|1||Normal healthy patient|
|2||Patient with mild systemic disease|
|3||Patient with a severe systemic disease that limits activity but is not incapacitating|
|4||Patient with an incapacitating systemic disease that is a constant threat to life|
|5||Moribund patient not expected to survive 24 hours with or without operation|
|Category IA||Well designed, experimental, strong; recommended (Category I*) clinical or epidemiological best practice; should be studies; adapted by all practices|
|Category IB||Some experimental, fairly strong; recommended (Category II*) clinical or epidemiological best practice; should be studies and theoretical grounds; adapted by all practices|
|Category II||Fewer scientific supporting data; limited to specific nosocomial (Category III*) problems|
|No recommendation||Insufficient scientific personnel judgment for use (Category III*) supporting data|
|*Previous nomenclature of 1992 CDC guidelines|