Transcript Pelvic Abscess

Post Gynecologic
Surgery Fever
Jamal MirzaeiMD. MPH
Infectious disease specialist
Post operative Fever
• T>38 oC : common in the first few days
• Early:
1. inflammatory stimulus of surgery (most)  resolve spontaneousely
2. 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 causes
a) 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 causes
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Surgical site infection
Pneumonia
UTI
Intravascular catheter associated infection
AB associated diarrhea
Sinusitis, Otitis media, parotitis, meningitis, IE, Osteomyelitis
Intra abdominal abscess
Acalculous cholecystitis
Transfusion associated viral infections
Foreign body infection (grafts, stents)
Timing of Fever
1. 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-Immediate
a) 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. Subacute
SSI
CVC infection
AB associated diarrhea
VAP,UTI, Sinusitis
Febrile drug reactions (Beta lactams, sulfa containing products)
Thrombophlebitis, DVT and pulmonary embolism
4. Delayed
Most 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
History
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Preoperative course and presentation
Operation (emergent or elective, intraoperative complications)
Postoperative course
PMH and comorbidities
Allergies
Medications
Location of catheter and time of placement
History
• Ask nurse:
• Sputum amount and quality
• Diarrhea
• Any areas of skin breakdown or rashes
• Ask patient:
• Cough
• pain
Physical examination
a) VS ( T, HR, RR)
b) Examine:
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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)
Laboratory
UA , 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:
1. Lactobacilli: produce both hydrogen peroxide and lactic acid protect
against the overgrowth of pathogens in the vagina
2. Streptococci
3. G. Vaginalis
4. Enterobacteriaceae
5. 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
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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 
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2.
amoxicillin/clavulanic acid
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 abscess
1. 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
2. culture (aerobic and anaerobic) purulent material
3. 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
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II.
III.
IV.
V.
G2: Cefoxitin (2gIV/QID) / Cefotetan (2g/IV/BID)
G3: Cefotaxime(1g/ IV/ TDS) / Ceftriaxone (2g/IV/stat then 1g/IV/D)
Ampi-Sulbactam (3g/IV/QID)
Ticarcilin/Clavulanic acid (3.1g/IV/Q4-6h)
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
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 surgery
2. 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
• Radiography or MRI:
• irregular bony margins and rarefaction and widening of the symphyseal
joint spaces
• Lab tests:
1. moderate leukocytosis
2. ESR
3. ALP
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
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