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Year : 2018  |  Volume : 55  |  Issue : 2  |  Page : 154--156

Superficial incisional surgical site infections in emergency surgery in cancer patients: A tertiary cancer care center experience

Rexeena Bhargavan, Paul Augustine 
 Department of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India

Correspondence Address:
Dr. Rexeena Bhargavan
Department of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala
India

Abstract

OBJECTIVE: The objective of this study is to review the superficial incisional surgical site infections (SISSIs) in emergency surgery in cancer patients. MATERIAL AND METHODS: The microbiological culture and sensitivity reports of patients undergoing emergency surgery for cancer of 1 year (April 2016 to March 2017) were analyzed along with the clinical factors associated with it from a surgeon's perspective. RESULTS: Of the 308 patients who underwent surgery, SISSI rate was 11.7%. The most common organism was Escherichia coli (27%) followed by enterococci (21%). Prolongation of hospital stay was average 2 days. Mortality rate among SISSI patients was 7.9%. Concordance among ongoing antibiotic and culture was 72%. CONCLUSION: Regular review of the current microbial spectrum and its antibiotic spectrum is required, especially in immunocompromized cancer patients.



How to cite this article:
Bhargavan R, Augustine P. Superficial incisional surgical site infections in emergency surgery in cancer patients: A tertiary cancer care center experience.Indian J Cancer 2018;55:154-156


How to cite this URL:
Bhargavan R, Augustine P. Superficial incisional surgical site infections in emergency surgery in cancer patients: A tertiary cancer care center experience. Indian J Cancer [serial online] 2018 [cited 2019 Nov 13 ];55:154-156
Available from: http://www.indianjcancer.com/text.asp?2018/55/2/154/249203


Full Text



 Introduction



Cancer patients are prone to infections due to their disease per say and because of the immunosuppressive treatment they receive. Superficial incisional surgical site infection (SISSI) is a common cause of postoperative complication that prolongs the hospital stay, increases cost, and causes severe distress to the patient. Most patients are elderly, nutritionally depleted, and have multiple comorbidities. The prolongation of postoperative recovery causes delay in the adjuvant treatment that has an adverse effect on the prognosis. Patients who undergo emergency surgery usually have a poor general condition, and hence, this complication is even grave. We conducted a retrospective study to evaluate our current postoperative SISSI rate in cancer patients undergoing emergency surgery.

 Materials and Methods



This is a retrospective review of adult cancer patients who underwent emergency surgery from April 2016 to March 2017 at our tertiary reference center (Regional Cancer Centre, Trivandrum, Kerala). Data was collected including the age, comorbidity, cancer site, type of surgery, neoadjuvant treatment received, organisms isolated in the culture report, antibiotic sensitivity, and hospital stay. The Centers for Disease Control and Prevention (CDC) definition of nosocomial infection was used.[1] All the pus samples were sent for aerobic and anaerobic cultures. The above data was evaluated to identify any factors that increased the risk of SISSI. The current microorganism spectrum and its antibiotic sensitivity trend was analyzed from a surgeon's perspective.

 Results



Three hundred and eight patients underwent emergency surgery during this period. Thirty-eight patients developed wound infections. The SISSI rate was 11.7%. The site of tumor and surgery done in patients with SISSI is depicted in [Table 1]. The most common surgery done was exploratory laparotomy with sigmoid colectomy for obstructing cancer of sigmoid colon, followed by surgery for reactionary hemorrhage after modified radical mastectomy for breast cancer. All patients received prophylactic antibiotic as per the department policy, that is, intravenous ceftriaxone 1.5 g and intravenous metronidazole 500 mg for gastrointestinal surgery cases and intravenous amoxicillin + clavulanic acid 1.2 g in nongastrointestinal cases half an hour before surgery. All gastrointestinal surgery patients were continued on the antibiotics till discharge. Daily evaluation of the wound was done using aseptic precautions. Once SISSI was detected, the antibiotics were stepped up to piperacillin + tazobactam as per department policy. The sensitivity report was available after 48 hours only. In cases where the culture report showed resistance to the ongoing antibiotics, it was changed as per the report. On univariate analysis, SISSI was more common among patients who underwent surgery for colorectal malignancies, had received neoadjuvant therapy (chemotherapy or radiation) and with a history of diabetes mellitus. Age, gender, history of cardiac illness, hypertension, and hypothyroidism were not. The microbial culture reports are depicted in [Table 2]. The most common organism was Escherichia coli present in 13 patients of which six were extended-spectrum beta-lactamases (ESBL) E. coli and three were multidrug-resistant (MDR) E. coli. ESBL organisms were sensitive to piperacillin + tazobactam whereas the MDR E. coli were sensitive to colistin. The second most common organism was enterococci. Methicillin-resistant Staphylococcus aureus was present in only one patient, which was sensitive to amikacin. MDR Klebsiella sensitive to tigecycline and MDR Enterococci sensitive to vancomycin were each present in one patient. Monobacterial infection was seen in 66% of the cases. The organisms were susceptible to the ongoing antibiotic in 72% of the cases that was piperacillin + tazobactam. The organisms were susceptible to amikacin in 76% of the cases. However, as the postoperative patients have a high risk of renal dysfunction, it was withheld. Nearly 72% of the patients had prolongation of hospital stay due to SISSI with a median prolongation of 2 days. There were three mortalities in this group. All three patients were colorectal malignancies and in whom cultures showed MDR organisms. Blood culture report was also the same in all three patients. All patients were started on the respective sensitive antibiotics after the availability of culture reports, but they succumbed to the sepsis. Thus, we had an overall mortality rate of approximately 1% in all emergency cases and of 7.9% in patients developing SISSI.{Table 1}{Table 2}

 Discussion



Cancer patients are prone to infections due to their immunoincompetence. This is due to multiple factors including the underlying malignancy and immunosuppressive therapy. Patients requiring emergency surgery are even more debilitated due to the various factors such as obstruction (most often caused by progression of the tumor), disruption of natural anatomic barriers such as the skin and mucosal surfaces causing bleeding and ulceration, and the associated malnutrition and cachexia. Infections in hematological malignancies have been well studied. However, there are limited data on infections in solid tumors and even a greater void on SISSI in emergency surgery in cancer patients. In most institutes, these patients receive empirical antibiotics once SISSI sets in which are changed after the culture reports are available. This usually takes at least 48 hours and valuable time is lost if the sensitive antibiotic is not started specifically as these patients are more immunosuppressed. Improper antibiotics are responsible for increasing cost, morbidity and in some cases mortality, prolonged hospital stay and delay in further treatment of these patients. Thus, it is important to regularly study microbiological sensitivity patterns and to update the antibiotics accordingly. In this study, we have retrospectively analyzed the SISSI rates and the culture and sensitivity reports in the emergency cancer surgery patients. As per our research, this is the first study of SISSI in emergency cancer surgeries from India.

We analyzed the data of 308 adult patients who underwent emergency surgery for solid malignancies. We used the CDC definition of SISSI. As per this definition, SISSI is infection that involves only skin and subcutaneous tissue of the incision site and occurs within 30 days after the operation and has at least one of the followings: (1) purulent drainage with or without laboratory confirmation, from the superficial incision, (2) organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision, (3) at least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat and superficial incision is deliberately opened by surgeon unless incision is culture negative, and (4) diagnosis of superficial incisional SSI made by a surgeon or attending physician. Our SISSI rate was 11.7%. In a study from another cancer center in India by Siddiqui et al., the wound infection rate was 8.74%.[2] These included routine and emergency surgeries. We had a higher SISSI rate than this study as we included only emergency cases. In a study by Masanori et al. on emergency colorectal surgeries, the SISSI rate was 32.1%.[3] The higher rates of infection in emergency surgeries can be attributed to inadequate preoperative preparation, the underlying conditions that predisposed to the emergency surgery, and the more frequency of contaminated or dirty wounds in emergency surgeries.

SISSI is a multifactorial condition. It has been associated with the type of surgery, wound classification, volume of blood loss, blood transfusion, preoperative ASA score, operative duration, diabetes, cancer, age, and many more factors.[4] Many studies have given controversial results with respect to these factors. As per Peter et al., surgery for abdominal cancer is associated with a higher degree of morbidity and mortality than other standard procedures.[5] Vilar-Compte et al. in their study found diabetes mellitus, obesity, and prolonged presence of a surgical drain as risk factors for SSI.[6] Whereas Sotirović et al. concluded that age, sex, body mass index, history of smoking, and underlying diabetes mellitus were not associated with increased risk for SSI.[7] In our study, on univariate analysis, the factors contributing to increased SISSI include colorectal malignancies, previous neoadjuvant therapy, and history of diabetes mellitus all of which are nonmodifiable risk factors. Age, gender, history of cardiac illness, hypertension, and hypothyroidism were not contributory factors.

All our pus cultures included both aerobic and anaerobic cultures. The most common organism was E. coli present in 13 patients (27%) of which six were ESBL E. coli and three were MDR E. coli. The second most common was enterococci. In the study by Siddiqui et al. of Indian cancer patients, the most common organism was S. aureus followed by E. coli.[2] In another series by Sumathi et al., the most common organism was E. coli followed by Klebsiella species.[8] In their series, most of the infections were polymicrobial, whereas in the series, Kenneth Rolston et al. (2015) on SSIs in cancer patients, 58% were monomicrobial and 42% were polymicrobial.[9] In our study, monobacterial infection was seen in 66% of the cases. The microorganisms were predominantly from the alimentary tract very similar to the report of Sipsas et al.,[10] where the prominent pathogens in neutropenic hosts were from the alimentary tract.

The study by Siddiqui et al. showed a very high resistance among the Gram-negative bacteria (GNB) against various antibiotics. Seventy-one percent of GNB were ESBL producers. ESBL production in E. coli and Klebsiella was 68% and 66%, respectively.[2] Fortunately, in our series, ESBL rate was 16% and MDR was 13%.

All patients received prophylactic antibiotic as per the department policy, that is, intravenous ceftriaxone 1.5 g and intravenous metronidazole 500 mg for gastrointestinal surgery cases and intravenous amoxicillin + clavulanic acid 1.2 g in nongastrointestinal cases half an hour before surgery. All gastrointestinal surgery patients were continued on the antibiotics till discharge as per our policy. Daily evaluation of the wound was done using aseptic precautions. Once SISSI was detected, the antibiotics were stepped up to piperacillin + tazobactam as per department policy which was formed based on previous audits. In our study, also the microorganisms were sensitive to piperacillin + tazobactam in 72% of the cases and to amikacin in 76%. As our patients are usually of high-ASA index, we preferred to avoid nephrotoxic drugs such as amikacin. The patients were discharged after the infection subsided and there was an average of 2-day delay in discharge due to SISSI. The antibiotics used were in par with culture sensitivity report with majority of the patients having improvement in the surgery site after regular dressing and antibiotics.

We had an overall mortality rate of approximately 1% in all emergency cases and of 7.9% in patients developing SISSI. They occurred in patients with MDR Gram-negative organism infection and their blood cultures also yielded the same organisms. All patients were started on the respective sensitive antibiotics after the availability of culture reports, but they succumbed to the sepsis. The SISSI may have been just a manifestation of the overall sepsis in these patients.

 Conclusion



The impact of SISSI in cancer patients is more than that in regular patients because of their immunosuppressed status and the need for further therapy after the surgery. Regular audits are required to study the antimicrobial spectrum prevalent in the hospital so that if infections do occur, time is not lost in while awaiting the culture reports which may push the patient into sepsis. A stitch in time saves nine.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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