Decolonization of the Skin of the Patient and Surgeon

Objective: To review the evidence regarding antisepsis and decolonization of the skin of the patient and surgeon for the prevention of surgical site infection (SSI). Data Sources: General bibliographic and specialist computer databases, along with manual searching of reference lists of primary and review articles, were used to search for relevant peer-reviewed citations Results: Antisepsis of the surgical site and of the hands of the surgeon is a mainstay in the prevention of SSI. Waterless and scrubless alcohol-based products are an alternative to traditional antiseptic scrubs. Chlorhexidine-based products for skin preparation at the surgical site have proved superior to other preparation products for bacterial decolonization. The efficacy of routine preoperative decolonization strategies, including the use of nasal mupirocin ointment and antiseptic body washes, has not been established definitively by randomized clinical trials Conclusions: Antisepsis of the skin of patient and surgeon are important in the prevention of SSI. Preoperative decolonization strategies for prevention of SSI, particularly those caused by antibiotic-resistant organisms, remain controversialPeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63229/1/sur.2006.7.s3-3.pd

Emerging Issues in the Diagnosis and Management of Infections Caused by Multi-Drug-Resistant, Gram-Positive Cocci

ABSTRACT Background: Rising rates of multi-drug-resistant, gram-positive cocci (e.g., methicillin-resistant Staphylococcus aureus [MRSA], vancomycin-resistant Enterococcus spp. [VRE]) have created treatment challenges for clinicians in both the hospital and community settings. These organisms have become especially problematic for hospitalized patients with pneumonia, complicated intra-abdominal infections, and skin and skin-structure infections (SSSIs). Methods: A review of the recent literature (1990 onwards) was undertaken in order to review the epidemiology, diagnostic issues, and clinical trial data of available and forthcoming therapies for the treatment of multi-drug resistant, gram-positive isolates, with an emphasis on selected MRSA infections (i.e., pneumonia, SSSI, diabetic foot infections, blood stream) and infections caused by VRE. Results: The rate of healthcare-associated MRSA in 2004 rose to an incidence of 59.5% in the United States compared with data from 1998–2002, making MRSA the predominant grampositive etiology of S. aureus infections in hospitalized patients. Methicillin-resistant S. aureus has also emerged as an important pathogen in both the non-ICU and community settings. Similarly, 28.5% of all enterococcal isolates were identified as vancomycin-resistant in 2003 (a 12% increase). However, these rates may be underestimated, as detection methods for determining susceptibility have proved to be inadequate. Recognition that prior inadequate antibiotic therapy is common in patients with antibiotic-resistant bacteria, and is associated with higher mortality rates, emphasizes the importance of selecting appropriate empiric therapy. Currently available therapies for resistant gram-positive infections include quinupristindalfopristin, linezolid, and daptomycin, although each of these agents has limitations (e.g., daptomycin is not indicated for MRSA pneumonia due to inadequate lung tissue penetration and inactivation by surfactant). Three agents with broad-spectrum activity against gram-positive organisms that are at an advanced stage of testing include two new glycopeptides (oritavancin and dalbavancin), and a first-in-class glycylcycline (tigecycline). These agents have demonstrated efficacy in the treatment of SSSIs, including those caused by MRSA. Conclusions: New antimicrobial agents are needed to combat the increasing prevalence of multi-drug-resistant, gram-positive pathogens such as MRSA. The emergence of resistance to available therapies such as vancomycin underscores this urgency.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63395/1/sur.2005.6.s2-5.pd

Aeromonas Pneumonia in a Trauma Patient Requiring Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome: Case Report and Literature Review

Background: Aeromonas species, particularly Aeromonas hydrophila, cause a wide spectrum of diseases in human being such as gastroenteritis; soft tissue infections including necrotizing fasciitis, meningitis, peritonitis, and bacteremia; but pneumonia and respiratory tract infections are uncommon. Methods: Case report and literature review. Results: A 30-year-old victim of a motor vehicle crash sustained pelvic fractures and splenic injury. Delayed splenic rupture caused sudden cardiorespiratory arrest. The patient was resuscitated but suffered septic shock and severe hypoxemia refractory to advanced mechanical ventilatory strategies. Aeromonas hydrophila was isolated as the causative pathogen of severe bilateral pneumonia. Venovenous extracorporeal membrane oxygenation (ECMO) was used temporarily. The patient recovered uneventfully. Conclusion: This is the first case, to our knowledge, of the use of ECMO in a trauma patient with severe fulminant A. hydrophila pneumonia. Clinicians should be aware of the characteristics of this pathogen and associated clinical infections.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90457/1/sur-2E2010-2E037.pd

Clostridium difficile Infection: Update on Diagnosis, Epidemiology, and Treatment Strategies

Background: Clostridium difficile infection (CDI) has increased in incidence and severity over the past quarter century, and is now considered a major cause of healthcare-associated infections. Methods: Review of the pertinent English-language medical literature. Results: There has been a substantial change in the management of CDI. The emergence of the NAP1/BI/O27 strain in the early to mid-2000s has been associated with more severe forms of CDI. The pathophysiology, epidemiology, clinical manifestations and diagnosis, as well as new strategies for medical and surgical management are discussed in this review. Conclusions: Clostridium difficile infection can range from benign diarrhea to severe disease associated with substantial morbidity and mortality. Treatment modalities vary based on disease severity and timing of onset. The mainstay of medical treatment remains metronidazole and oral/rectal vancomycin. New management strategies are evolving, including adjunctive treatments such as monoclonal antibodies, vaccination, and fecal transplant. In patients with severe disease or clinical deterioration, early surgical consultation for total colectomy or loop ileostomy may be life-saving. Infection control measures are vital to mitigating the spread of CDI.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140215/1/sur.2013.186.pd

How do we treat life‐threatening anemia in a J ehovah's W itness patient?

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/109968/1/trf12888.pd

Necrotizing Pancreatitis: New Definitions and a New Era in Surgical Management

Background: Necrotizing pancreatitis is a challenging condition that requires surgical treatment commonly and is associated with substantial morbidity and mortality. Over the past decade, new definitions have been developed for standardization of severity of acute and necrotizing pancreatitis, and new management techniques have emerged based on prospective, randomized clinical trials. Methods: Review of English-language literature. Results: A new international classification of acute pancreatitis has been developed by PANCREA (Pancreatitis Across Nations Clinical Research and Education Alliance) to replace the Atlanta Classification. It is based on the actual local (whether pancreatic necrosis is present or not, whether it is sterile or infected) and systemic determinants (whether organ failure is present or not, whether it is transient or persistent) of severity. Early management requires goal-directed fluid resuscitation (with avoidance of over-resuscitation and abdominal compartment syndrome), assessment of severity of pancreatitis, diagnostic computed tomography (CT) imaging to assess for necrotizing pancreatitis, consideration of endoscopic retrograde cholangiopancreatography (ERCP) for biliary pancreatitis and early enteral nutrition support. Antibiotic prophylaxis is not recommended. Therapeutic antibiotics are required for treatment of documented infected pancreatic necrosis. The initial treatment of infected pancreatic necrosis is percutaneous catheter or endoscopic (transgastric/transduodenal) drainage with a second drain placement as required. Lack of clinical improvement after these initial procedures warrants consideration of minimally invasive techniques for pancreatic necrosectomy including video-assisted retroperitoneal debridement (VARD), minimally invasive retroperitoneal pancreatectomy (MIRP), or transluminal direct endoscopic necrosectomy (DEN). Open necrosectomy is associated with substantial morbidity, but to date no randomized trial has documented superiority of either minimally invasive or open surgical technique. Additional trials are underway to address this. Conclusions: Severe acute and necrotizing pancreatitis requires a multi-disciplinary treatment strategy that must be individualized for each patient. Optimal treatment of necrotizing pancreatitis now requires a staged, multi-disciplinary, minimally invasive ?step-up? approach that includes a team of interventional radiologists, therapeutic endoscopists, and surgeons.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140218/1/sur.2014.123.pd

Mucinous Appendiceal Tumor Presenting as Perforated Appendicitis

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140216/1/sur.2013.238.pd

Stump Appendicitis

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140214/1/sur.2013.163.pd