From the Guidelines
Surgical site infections (SSIs) after lower extremity amputations should be managed with prompt identification, appropriate antimicrobial therapy, and surgical intervention when necessary, with initial empiric antibiotic therapy including coverage for both gram-positive and gram-negative organisms, typically with vancomycin 15-20 mg/kg IV every 12 hours plus piperacillin-tazobactam 4.5g IV every 6-8 hours, or cefepime 2g IV every 8 hours, as recommended by the 2018 WSES/SIS-E consensus conference 1.
Key Considerations
- SSIs are classified into superficial incisional infection, deep incisional infection, and organ space infection, with deep incisional and organ/space infections causing the most morbidity 1.
- The pathogens isolated from infections differ depending on the type of surgical procedure, with Staphylococcus aureus being the usual cause of infection in clean surgical procedures, and aerobic and anaerobic pathogens of the normal endogenous microflora being the most frequently isolated pathogens in clean-contaminated or contaminated surgical procedures 1.
- Important host factors that determine the risk of SSI include age, malnutrition status, diabetes, smoking, obesity, colonization with microorganisms, length of hospital stay or previous hospitalization, shock and hypoxemia, and hypothermia 1.
Management and Prevention
- Incisional SSIs should always be drained, irrigated, and if needed, opened and debrided, with percutaneous drainage, wound irrigation, and negative pressure-assisted wound management being new and effective options that reduce the need for open management of wound infections 1.
- Empiric broad-spectrum antibiotic treatment should be initiated in patients with incisional SSIs with the presence of any systemic inflammatory response criteria or signs of organ failure, such as hypotension, oliguria, decreased mental alertness, or in immunocompromised patients 1.
- Prevention strategies include preoperative antibiotics, typically cefazolin 2g IV within 60 minutes before incision, meticulous surgical technique, glycemic control in diabetic patients, and proper postoperative wound care 1.
Treatment Duration and Adjustment
- Treatment duration is generally 7-14 days depending on infection severity, with adjustment based on culture results 1.
- The guidelines recommend that antibiotic prophylaxis should be used to prevent infections before and during surgery only, and not after surgery, with administration of the first dose of antibiotics within 120 min prior to the incision 1.
From the Research
Surgical Site Infections after Lower Extremity Amputation
- The incidence of surgical site infections after lower extremity amputation is not directly addressed in the provided studies 2, 3, 4, 5, 6.
- However, study 2 mentions that "No differences were found in the incidence of surgical site complications or unplanned readmissions between the two groups" when comparing the lower extremity amputation protocol (LEAP) with historic controls.
- Study 3 reports on the outcomes of lower extremity amputations, including perioperative mortality and morbidity, but does not specifically focus on surgical site infections.
- Studies 4, 5, 6 discuss the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections and the use of various antibiotics, but do not provide information on surgical site infections after lower extremity amputation.
Related Outcomes
- Study 2 found that the use of LEAP can significantly decrease postoperative length of stay and expedite the time to independent ambulation with a prosthesis for vascular patients undergoing a major lower extremity amputation.
- Study 3 reports that patients requiring major lower extremity amputation represent a high-risk population with significant perioperative morbidity and limited survival.
- Studies 4, 5, 6 provide information on the treatment of MRSA infections, which can be relevant to the management of surgical site infections, but do not directly address the incidence of surgical site infections after lower extremity amputation.