Biomedical subjects
Publications and source records attributed to H H Stone.
Soft tissue infections are almost routinely the product of direct microbe inoculation through a bridged protective skin. Day of onset and clinical presentation reflect the causative pathogen(s) and course that should be taken in treatment. Exclusive of chronic states, only in the most fulminating cases are culture and antimicrobial drugs of any real value.
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This prospective, open, consecutive, nonrandomized trial examined management techniques and outcome in severe peritonitis. A total of 239 patients with surgical infection in the abdomen and an APACHE (acute physiology and chronic health evaluation) II score greater than 10 were studied. Seventy-seven patients (32%) died. Reoperation had a 42% mortality rate (35 of 83 patients died) compared with a 27% mortality rate (42 of 156 died) in patients who did not undergo reoperation. Forty-six patients underwent one reoperation; 15, two reoperations; 10, three reoperations; five, four reoperations; and seven, five reoperations, with mortality rates of 43%, 40%, 30%, 40%, and 57%, respectively. There was no significant difference in mortality between patients treated with a "closed-abdomen technique" (31% mortality) and those treated with variations of the "open-abdomen" technique (44% mortality). Logistic regression analysis showed that a high APACHE II score, low serum albumin level, and high New York Heart Association cardiac function status were significantly and independently associated with death. Low serum albumin level, youth, and high APACHE II score were significantly and independently associated with reoperation.
To denervate the pancreas of sensory afferents, 15 patients with intractable pain of chronic alcohol induced pancreatitis underwent left transthoracic splanchnicectomy with concomitant bilateral truncal vagotomy. All were malnourished and 11 were addicted to opiates. No respite had been obtained from 33 previous operative procedures. Each patient experienced almost immediate pain relief. Five, however, later had return of pain, but only to the right epigastrium. These five then underwent right transthoracic splanchnicectomy, after which four noted complete and apparently permanent disappearance of pain. In those 14 with a successful outcome there has been a 29 per cent mean increase in body weight, break of hard drug addition in ten of the 11 so afflicted, and return to gainful work or a relatively normal lifestyle in all 14 at a mean follow-up of 16 months. Although 11 of the 14 do have delayed gastric emptying, only one has required a drainage procedure. There have been no other late complications. This approach for control of incapacitating pain in chronic pancreatitis is both safe and simple and at the same time it appears to be reasonably reliable.
The enterococcus has been relegated to a position of unimportance in the pathogenesis of surgical infections. However the increasing prevalence and virulence of these bacteria prompt reconsideration of this view, particularly because the surgical patient has become increasingly vulnerable to infectious morbidity due to debility, immunosuppression, and therapy with increasingly potent antibiotics. The enterococcus is a versatile opportunistic nosocomial pathogen, causing such diverse infections as wound, intra-abdominal, and urinary tract infections; catheter-associated infection; suppurative thrombophlebitis; endocarditis; and pneumonia. Although surgical drainage remains the cornerstone of therapy for enterococcal infections involving a discrete focus, in the circumstances typified by the compromised surgical patient, specific antibacterial therapy directed against the enterococcus is warranted. Recent evidence indicates that parenteral antibiotic therapy for enterococcal bacteremia is mandatory and that appropriate therapy clearly reduces the number of deaths.
The safety and effectiveness of a single 2 g preoperative dose of cefotetan to reduce postoperative infectious complications after colorectal surgery was compared with multiple 2 g perioperative doses of cefoxitin in 289 patients enrolled in a multicenter trial; of the 239 evaluable patients, 164 received cefotetan and 75, cefoxitin. No statistically significant difference was detected in the successful clinical response rates for cefotetan and cefoxitin (88 percent and 92 percent, respectively). The difference in median increase in oral body temperature before and after the study (2.5 degrees F for cefotetan and 2 degrees F for cefoxitin) was statistically but not clinically significant (p = 0.03). Although nearly four times as many cefotetan patients as cefoxitin patients had surgery lasting 4 hours or more, the satisfactory bacteriologic response rates for cefotetan and cefoxitin were similar (88 percent and 93 percent, respectively). Nonobese patients and patients whose surgical procedures lasted less than 4 hours treated with either drug had significantly higher success rates (p less than 0.01). The incidence of major wound infection was approximately 8 percent for both treatment groups. Mean concentrations of cefotetan in plasma, specimens of colon, and subcutaneous fat were 128 +/- 61.8 micrograms/ml, 57.2 +/- 40.4 micrograms/g, and 26.8 +/- 19.4 micrograms/g, respectively. The incidence of adverse reactions was 12 percent for each group, and no reaction was considered treatment-related, including changes in results of clinical laboratory tests. A single 2 g preoperative dose of cefotetan was as safe and effective as multiple doses of cefoxitin in the reduction of postoperative wound infections after colorectal surgery.
One hundred eighty-eight patients were enrolled in a multicenter, randomized clinical trial to compare the safety and effectiveness of 1 to 2 gm cefotetan every 12 hours with those of 1 to 2 gm cefoxitin every 6 hours in patients with intra-abdominal infections. Most of the infections were community acquired, were associated with gastrointestinal tract perforation, and were caused by both anaerobic and aerobic bacteria. The median duration of therapy was 6 days for each group. The clinical response rate for the 95 evaluable patients in the cefotetan group was 98%, and that for the 43 evaluable patients in the cefoxitin group was 95%. Bacteriologically, 97% of the 58 evaluable patients in the cefotetan group and 89% of the 27 evaluable patients in the cefoxitin group had a satisfactory or presumed satisfactory response; two patients in the cefotetan group and three in the cefoxitin group were considered bacteriologic failures. Cefotetan was as effective as cefoxitin in eradicating Bacteroides fragilis and other species of Bacteroides, Clostridium sp., and gram-negative bacilli. The incidence of treatment-related adverse reactions for cefotetan (27%) was not statistically different from that for cefoxitin (17%). No clinically significant differences were detected between the treatment groups in changes in the results of clinical laboratory tests performed before and after treatment; a decrease in hematocrit among the cefotetan group was statistically greater (p = 0.04) than that for the cefoxitin group, and a decrease in serum creatinine level for the cefoxitin group was greater than that for the cefotetan group (p = 0.02). Cefotetan may represent an effective, safe, and cost-saving alternative to cefoxitin for the prompt treatment of community-acquired intra-abdominal infections.
The majority of surgical infections are due to multiple bacterial pathogens, usually represented by mixtures of both aerobic and anaerobic species. Contamination from endogenous sources accounts for the majority of these infections. The most virulent of all such sepsis appears to arise from a symbiosis between aerobic gram-negative rods and various anaerobes. Antibiotics have proved efficacy in both the treatment as well as the prevention of surgical infection. The choice of antimicrobial agent(s) should be based upon the drug's spectrum of activity against known or anticipated pathogens, the biologic half-life of the agent, which serves as a guide to the frequency of administration, and the drug's safety. The third-generation cephalosporins have been shown to be especially useful because of their broad spectrum of activity, prolonged half-life, and limited toxicity. Sepsis that persists or is uncontrolled despite antibiotic administration often leads to failure of multiple organ systems. Only energetic surgical measures offer any real chance for patient survival when such a stage has been reached.
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The treatment of 77 patients with wounds of the inferior vena cava admitted to Grady Hospital, Atlanta, Georgia, from January 1972 through December 1983, was reviewed. All injuries were identified by laporotomy and/or thoracotomy. Trauma resulted from gunshot wounds in 79 per cent of patients, stab wounds in 18 per cent, and blunt trauma in 3 per cent, with an overall mortality of 30 per cent. The chief determinates of survival were preoperative hypotension, location of the injury and the presence of other major vascular injuries. Of the 49 patients admitted in shock, 22 (45%) died, all of complications related to organ ischemia. Only one patient not hypotensive on admission succumbed. Of the 29 patients with at least one additional injury to a major vascular structure, 45 per cent died. The mortality of infrarenal and suprarenal injuries was relatively low (22% and 33% respectively), compared with retrohepatic and supradiaphragmatic injuries, both of which were fatal in 67 per cent of the cases. Despite advances in the care of the trauma patient, significant improvement in survival has not occurred, and the patient mortality has remained at 30 per cent.
We reviewed the charts of 2,567 patients from 11 prospective clinical trials of antibiotic therapy for surgical infection to identify reliable predictors of sepsis eradication. Particular attention was paid to temperature, blood cell counts, renal and hepatic function tests, arterial gases, and clotting factors, both at the termination of parenteral antibiotic administration as well as at patient discharge from the hospital. On the discontinuation of antibiotic therapy, sepsis recurred in 19% of the patients who had a normal rectal temperature, in 3% of the patients if the rectal temperature and WBC count were normal, but in no patient when both the temperature and WBC count were normal and the differential blood smear contained less than 73% granulocytes and less than 3% immature forms. Rates for recurrent sepsis, once antibiotic therapy was discontinued for more than 48 hours, were 8%, 2%, and 0%, respectively, for the same criteria at hospital discharge.
Three retrospective reviews documenting a lessened frequency of acute recurrent alcohol-induced pancreatitis following vagotomy, with or without gastrectomy or gastroenterostomy, prompted a prospective evaluation of truncal vagotomy with Bilroth II gastrectomy as a means of preventing such exacerbations. Randomization between operation and encouragement to abstain from alcohol in patients with a history of more than one, but less than ten, acute bouts of alcohol-induced pancreatitis was set by odd-even digits in the hospital number. Of 176 patients admitted with acute alcoholic pancreatitis during 23 months of study, 49 were excluded because of too few or too many prior attacks. Another 61 refused to enter the study. At least one (average 1.9) recurrence requiring hospitalization was noted in 49, or 80%, of these patients on follow-up for 2 to 26 months (average 14 months). Of the 66 who consented to participate, 33 were randomized not to undergo operation and had almost identical recurrence statistics (i.e., an average of 1.7 recurrences in 24, or 73%). By contrast, only two of 31, or six per cent, allocated to operation have experienced a recurrence (p less than 0.001). Two who had been randomized were excluded because of persisting active pancreatitis.
Routine drainage of liver wounds created by trauma has recently been challenged, prompting a prospective, randomized trial of drainage via a Penrose dam versus no drain in patients having emergency laparotomy for abdominal trauma. We excluded cases in which definite bile leak was noted at operation. Of 167 patients studied, six had obligatory drainage because of obvious bile leak. Among the remaining 161 patients, there was no significant difference as to demographics, mode of injury, volume of blood lost or used for resuscitation, incidence and severity of shock, number and types of associated injuries, or magnitude of liver wound between the 78 allocated to drainage and the 83 left without a drain. Resultant mortality, duration of hospitalization, incidence of wound and/or intra-abdominal infection, and likelihood of subsequent bile fistula were not different. Such data support the routine use of a drain only if bile leakage from the liver wound is found at laparotomy. Without obvious bile leak, drainage of a specific liver injury does not appear to be necessary.
During a 7 month trial for therapy of polymicrobial surgical sepsis, intravenous antibiotic treatment was randomized between gentamicin (1 mg/kg every 8 hours) plus clindamycin (8 mg/kg every 6 hours), and the cephalosporin, ceftriaxone (1 g every 12 hours) in 197 patients, of whom 99 were being treated for peritonitis, 93 for soft tissue sepsis, and 5 for other forms of infection. No significant differences were noted in patient demographics, type of sepsis, associated disease states, surgical procedure, or causative aerobic or anaerobic pathogens. Results demonstrated approximately equivalent efficacy, although cure rates obtained with ceftriaxone in patients with soft tissue sepsis or intraabdominal abscess were superior to those achieved with combination gentamicin and clindamycin. There were no significant side effects with ceftriaxone therapy, such as the renal failure noted in six of the patients treated with gentamicin and clindamycin. We conclude that single agent treatment with ceftriaxone is preferable because of the greater safety and the longer dosing intervals.
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The prophylactic administration of antibiotic to the surgical patient is generally indicated whenever complicating infection of the incision or coelom to be violated is associated with a significant morbidity and/or mortality rate. For maximal benefit, antibiotic must be in the tissues at risk just prior to and throughout the entire period of bacterial contamination. When a parenteral route for delivery is uncertain, as in the case of shock or a burn wound, then topical application becomes a practical alternative. Only hospital surveillance, however, can dictate which patients and which surgical procedures warrant prophylactic antibiotic. Intelligently implemented, such a preventive programme can reduce significantly total expenditure for surgical health care.
Controversy as to whether the intra-abdominal abscess should be drained extraperitoneally or through formal laparotomy still rages. Arguments for a transperitoneal approach include no need to identify specific locus preoperatively and uniform drainage of all abscesses, especially any otherwise unrecognized pus collection. Proponents for the extraperitoneal route stress failure to contaminate previously uninvolved peritoneal spaces and more reliable avoidance of injury to intestine, predisposing to subsequent intestinal fistula. To resolve this impasse, a prospective study of each method was based upon a schedule of previously randomized treatment options. After 32 months of study, 60 patients had been enrolled without obvious differences between treatment groups with respect to demographic features, preoperative definition and locus of infection, precipitating cause of sepsis, associated diseases, responsible bacteria and antibiotic therapy. With the transperitoneal approach, five patients had hollow viscus injury, while seven eventually had an intestinal fistula develop, causing major problems in four. Despite no obvious intestinal injury with the extraperitoneal route, two transient intestinal fistulas did occur. Seven patients drained transperitoneally had additional abscesses discovered, yet another operation was required to drain at least one complicating abscess in seven of this same group. With the extraperitoneal route, only two patients needed reoperation to drain another abscess. Although there were more deaths and complications in the group drained transperitoneally, morbidity (47 per cent) and mortality (7 per cent) were not significantly different statistically. Such data refute the professed superiority of a transperitoneal approach to intra-abdominal abscess drainage, both from need to reoperative for second abscess as well as incidence of latter intestinal fistula. Best results were noted with abscess identification through computerized tomography followed by extraperitoneal drainage.
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