Jamal Mirzaei MD. MPHJamal Mirzaei MD. MPHInfectious disease specialistInfectious disease specialist

Post Post Gynecologic Gynecologic

Surgery FeverSurgery Fever

Post operative Fever

• T>38 oC : common in the first few days

• Early: 1. inflammatory stimulus of surgery (most) resolve

spontaneousely2. Manifestation of a serious complication

Pathophysiology of postoperative fever• various stimuli tissue trauma cytokine release

(IL1,6,TNF, IFN-gamma) FEVER

• Bacterial endotoxins and exotoxins stimulate cytokines postoperative fever

Causes of postoperative fever

1. Non infectious causesa) Surgical site inflammation without infection

(Hematoma,Suture reaction)

b) Thrombosis (DVT, Pulmonary emboli)

c) Inflammatory (gout, pancreatitis)

d) Vascular (cerebral infarction, ICH, SAH,MI, Bowel ischemia/infarction)

e) Other (medications,transfusion reaction,drug/alcohol withdrawal, cancer/neoplastic fever)

2. Infectious causesa) Surgical site infectionb) Pneumoniac) UTId) Intravascular catheter associated infectione) AB associated diarrheaf) Sinusitis, Otitis media, parotitis, meningitis, IE,

Osteomyelitisg) Intra abdominal abscessh) Acalculous cholecystitisi) Transfusion associated viral infectionsj) Foreign body infection (grafts, stents)

Timing of Fever1. Immediate: in the operating room or within hours

after surgery

2. Acute: within the first week after surgery

3. Subacute: 1-4w after surgery

4. Delayed: > 1m after surgery

1-Immediatea) Medications or blood products

b) Trauma (before surgery or as a part of surgery)

c) Infections before surgery

d) Malignant hyperthermia (rare) (inhaled anesthetics, succinylcholine)

2. Acute• Nosocomial infections:

VAP and aspiration pneumonia

UTI

SSI (GAS and Clostridium perfringens)

Catheter exit site infections and bacteremia

3. SubacuteSSI

CVC infection

AB associated diarrhea

VAP,UTI, Sinusitis

Febrile drug reactions (Beta lactams, sulfa containing products)

Thrombophlebitis, DVT and pulmonary embolism

4. DelayedMost of them are due to infection

• Viral and parasitic infections from blood products (CMV, Hepatitis viruses, HIV, Toxo, Babesios, Plasmodium Malariae)

• SSI due to more indolent MO (CONS)

• IE (due to perioperative bacteremia)

Evaluation of patient with postoperative fever

History1. Preoperative course and presentation2. Operation (emergent or elective, intraoperative complications)

3. Postoperative course4. PMH and comorbidities5. Allergies6. Medications7. Location of catheter and time of placement

History

Physical examinationa) VS ( T, HR, RR)b) Examine:• Skin (rash, ecchymoses, injection site erythema, hematoma)

• Lung• Heart (tachycardia, new murmur)

• Abdomen (tenderness, BS)

• Operative site and lymphatic drainage• Catheter entry sites• Lower legs (for evidence of DVT)

LaboratoryUA , UC

B/C (peripheral and catheter)

Sputum (smear, culture)

Wound culture

CXR

SURGICAL SITE INFECTION AFTER

GYNECOLOGIC SURGERY

SSIs associated with hysterectomy

1. Vaginal cuff cellulitis

2. vaginal cuff abscess

3. pelvic abscess

SSIs associated with hysterectomy• source of pathogens : endogenous microbiota of

the vagina

• The normal vaginal microbiota: • Lactobacilli: produce both hydrogen peroxide and lactic

acid protect against the overgrowth of pathogens in the vagina

• Streptococci• G. Vaginalis• Enterobacteriaceae• Anaerobes

SSIs associated with hysterectomy

• Excision of the cervix breached vaginal epithelium MO gain entry to the vaginal cuff, paravaginal tissues, and peritoneal cavity

Cuff Cellulitis

Cuff Cellulitis• inflammatory response at the margins of the vaginal

cuff incision

• a normal part of the healing process in the early posthysterectomy Period

• Host defense mechanisms quickly resolve it in most patients without the need for AB

Cuff Cellulitis• Clinical Findings in patients require AB• present within 10 d after surgery• central lower abdominal and pelvic pain• vaginal discharge• low-grade fever• Abdominal examination: slight suprapubic tenderness to deep

palpation• bimanual examination only the vaginal surgical margin is

tender and no masses are palpable

Cuff Cellulitis• Treatment:• OPT with AB regimen that includes coverage for anaerobic

MO 1. amoxicillin/clavulanic acid 2. the combination of Metronidazole +

• G1 cephalosporin • FQ • trimethoprim/sulfamethoxazole

• monitor temperatures at home• clinical reevaluation if improvement in pain and T is not noted

by 72 h

vaginal cuff abscess

vaginal cuff abscess• A well-localized collection of pus just above the vaginal

cuff • develops in a few patients with cuff cellulitis

• CC: fever & sense of fullness (lower abdomen)

• PhE: Bimanual pelvic examination vaginal cuff mass

• Imaging: ultrasonography confirm the abscess

vaginal cuff abscess1. drainage facilitates cure

simply by dilation of the vaginal cuff in a treatment room

larger collections Sono or CT guided drainage or in the operating room

• culture (aerobic and anaerobic) purulent material• IV AB (Broad-spectrum) until defervescence for 24 to

36 h

Pelvic Abscess

Pelvic Abscess• Rare but the most serious late postop complication • Involve one or both residual adnexa (tubo-ovarian

abscess) • occur almost exclusively in premenopausal women• occur despite prophylactic AB• often have a latent period of many w between surgery

and onset of symptoms

Pelvic Abscess• fever (high spike late in the afternoon or early

evening)

• palpable mass high in the pelvis

• WBC: around 20,000/mm

• ESR

Pelvic Abscess

•Sono and CT :

1. confirm the presence of a mass

2. help to determine whether it is

• Loculated

• related to an intraperitoneal structure

• drainable percutaneously

Pelvic Abscess• Immediate drainage is not mandatory if it is

inaccessible AB therapy alone may be successful

• isolation of β-lactamase–producing Prevotella species use of clindamycin, metronidazole, or other agents against gram-negative anaerobes

Pelvic Abscess• clindamycin + gentamicin fails to respond drainage

• Necrosis+infections surgical exploration in some cases

• aerobic and anaerobic culture of purulent material or tissue

Pelvic Abscess• Duration of AB therapy:

1. IV AB until • defervescence for 48-72 h• NL leukocyte count • Resolved signs and symptoms

2. PO AB for 7 d after discharge:• amoxicillin/clavulanate• Metronidazole

• reexamine 2 w after discharge R/O recurrence or reaccumulation of the abscess

IV AB Regimens for Treating Gynecologic Postoperative

Infections

1. Localized infection with minimal systemic findings

I. G2: Cefoxitin (2gIV/QID) / Cefotetan (2g/IV/BID)

II. G3: Cefotaxime(1g/ IV/ TDS) / Ceftriaxone (2g/IV/stat then 1g/IV/D)

III.Ampi-Sulbactam (3g/IV/QID)

IV.Ticarcilin/Clavulanic acid (3.1g/IV/Q4-6h)

V. Piperacillin/Tazobactam (3.375g/IV/QID)

2. Extensive infection with moderate to severe systemic findings

I.Clinda (900/IV/TDS) + Genta (2mg/kg/stat then 1.5mg/kg/TDS) ± Ampi (2g/IV/stat then 1/IV/Q4h)

II.Ampi + Genta + Metro (500mg/IV/TDS)

III.Imipenem or Meropenem or Ertapenem(1g/IV/d)

IV.Levofloxacin (500mg/IV/d) + Metro

Osteomyelitis Pubis• Past: noninfectious, self-limited inflammatory

condition of the symphysis pubis associated with retropubic urologic procedures

• Now: It is a rare infection results from:1. direct inoculation of the bone at the time of surgery2. extension of a contiguous focus of infection

• in women : after urethral suspension, radical vulvectomy or pelvic exenteration

Osteomyelitis Pubis• Symptoms and Signs:

• suprapubic discomfort

• difficulty with ambulation and a wide-based waddling walk

• Wound drainage

• low-grade fever

Osteomyelitis Pubis

Osteomyelitis Pubis• Common isolated MO: • gram-negative bacteria • staphylococcal and streptococcal species

• Suggestive findings CT guided needle bone Bx histopathology and culture

A.recovered MO AB trial poor response debridement

B.MO not isolated open surgical Bx with debridement and culture directed AB for at least 4 weeks

mirzaei@dr.com