Postoperative Nosocomial Infections

Surgical patients are prone to develop a wide variety of nosocomial infections

during the postoperative period, which include SSIs, UTIs, pneumonia, and
bacteremic episodes. SSIs are discussed above, and the latter
types of nosocomial infections are related to prolonged use of indwelling
tubes and catheters for the purpose of urinary drainage, ventilation, and
venous and arterial access, respectively.
The presence of a postoperative UTI should be considered based on urinalysis
demonstrating WBCs or bacteria, a positive test for leukocyte esterase, or a
combination of these elements. The diagnosis is established after greater than
104 CFU/mL of microbes are identified by culture techniques in symptomatic
patients, or greater than 105 CFU/mL in asymptomatic individuals. Treatment
with a single antibiotic that achieves high levels in the urine is appropriate.
Postoperative surgical patients should have indwelling urinary catheters removed
as quickly as possible, typically within 12 days, as long as they are
mobile.
Prolonged mechanical ventilation is associated with an increased incidence
of pneumonia, and is frequently because of pathogens common in the
nosocomial environment. Frequently these organisms are highly resistant to
many
different agents. The diagnosis is established based on clinical criteria of
purulent sputum, fever, elevated WBC, and roentgenographic evidence of one
or more areas of pulmonary consolidation. Consideration should be given to
performing bronchoalveolar lavage to obtain samples to assess by Gram stain
and to performing a culture to assess for the presence of microbes. Surgical
patients should be weaned from mechanical ventilation as soon as feasible to
reduce the incidence of this complication.
Infection associated with indwelling intravascular catheters has become a
common problem among hospitalized patients. Because of the complexity of
many surgical procedures, these devices are increasingly used for physiologic
monitoring, vascular access, drug delivery, and parenteral nutrition. Among

the several million catheters inserted each year in the United States,
approximately 25 percent will become colonized, and approximately 5 percent
will be
associated with bacteremia. Many patients who develop intravascular catheter
infections are asymptomatic, often exhibiting an elevation in the WBC count.
Blood cultures obtained from a peripheral site and drawn through the catheter
that reveal the presence of the same organism increase the index of suspicion
for the presence of a catheter infection. Obvious purulence at the exit site
of the skin tunnel, severe sepsis syndrome because of any type of organism
when other potential causes have been excluded, or bacteremia because of
gram-negative aerobes or fungi should lead to catheter removal.