Post-Surgery Care: Focus on Infection Prevention (Pag-alaga sa Bagong Operada: Paano Iwasan ang Impeksyon)
Speakers: Dr. Ricardo M. Manalastas, Jr. and Dr. Ma. Angela S. Rodriguez-Bandola
Moderator: Dr. Florida F. Taladtad
Reactor: Ms. Marie Aileen Regina Dreyfus
Register for FREE to all webinars of the series at: https://tinyurl.com/MuWebReg2021
MUla Kay Doktora: The Dr. Julita Ramoso-Jalbuena Memorial Women’s Health Forum (Series):
• Executive Checkup: Design Your Own Health Checkup & Cancer Screening! (July 2021)
• How to Prepare for Surgery during Covid? (August 2021)
• How to Prevent Infection Post-Surgery? (September 2021)
Here’s the full transcript of the webinar:
[PANEL DISCUSSION PROPER]
DR. MANALASTAS: Common infections after giving birth will include infection of the episiotomy wound, which is caused by the incision made by the doctor on the delivering patient in the vaginal area and cesarean section wound also known as surgical site infection. Following pelvic surgery, particularly total hysterectomy, patients can have an abdominal wall incision infection – infection of the wound on the abdominal wall, also known as surgical site infection level 1 or 2. Some patients also develop cuff cellulitis
– cuff referring to the portion of the vaginal canal from where the cervix is cut along with the uterus, which it is a part of, gets infected. After removal of the uterus, the pelvic area is empty except for the intestines and bladder, and when infected, may develop into pelvic abscess.
Episiotomy can be a 1) median incision – more prone to extension in the anal canal, advantageous for being more anatomical, thus less painful or 2) mediolateral incision. When the episiotomy wound is infected, oral antibiotics such as co amoxiclav may be sufficient; some ancillary measures like warm compress and hot sitz bath may also help as it affords relief of edema, swelling, or pain. Patients are also put on stool softeners to avoid straining. Maintaining perineal hygiene with antiseptic soaps available in the market are also essential. Medications like analgesics and anti-inflammatory drugs are also given.
A dreaded complication for an improperly repaired and infected episiotomy wound is rectovaginal fistula, a communication between the vaginal canal and the anal tract. This is sometimes called obstetric anal sphincter injuries (OASIS). This may be problematic so the course of action is to treat the infection first, as with an infected episiotomy, followed by surgical repair of the defect (sphincteroplasty).
Surgical site incision (SSI) infection after cesarean section is categorized into three layers, depending on severity. Most are superficial and involve the skin and subcutaneous tissue, which are generally easy to treat. Deep, involving the muscle, fascia, and peritoneum will require more complicated treatment. The worst type of SSI involves the organ/space, either the pelvic organs such as the uterus, and may include the adnexa or bowels. All these may or may not be followed by dehiscence or breakdown of the wound.
Management for superficial SSI involves local wound care: regular cleaning with a topical antiseptic, washing with soap and water followed by application of topical antimicrobial, warm compress when accompanied by swelling, and in the presence of dehiscence, there may be a need for resuturing after resolution of infection.
In making a diagnosis for deep SSI, it is important to make sure that there is no Organ/Space SSI, especially uterine incision dehiscence or evisceration, because this will not be addressed without first correcting the defect in the uterus. Evisceration refers to disruption of the abdominal wall causing bowel to come out, a type of surgical emergency. Patients may present with fever, abdominal distention, tenderness/rebound. Aside from clinical evaluation, ultrasound may also be helpful. Systemic antibiotics may be given: empiric broad spectrum drugs like clindamycin in combination with aminoglycoside and penicillin/ampicillin. Patients may be advised to get admitted in the hospital. Local wound care measures are also important.
With the involvement of organ/space, as with “Deep SSI” measures are followed with the addition of surgical evacuation of focus of infection: debridement, repair, excision of necrotic tissue, lavage or washing of the peritoneal cavity, and drainage. In the presence of dehiscence, one will have to decide
between primary, delayed primary, or secondary closure as in diabetic, obese, or those with concomittant respiratory infection as their primary risk factors will have to be corrected first.
After pelvic surgery naman, after abdominal hysterectomy, again, the abdominal wound can be infected very similar to CS wound, without involvement of the uterus. Now, I mentioned cuff cellulitis kanina, this is a localized infection lang. But again, similar to deep SSI, we need to rule out a more severe infection involving the pelvic cavity like the bowel or the bladder as well. Cuff cellulitis is easy to treat also it’s a localized infection lang so generally, oral antibiotics will suffice for this condition.
This is the problematic part, the pelvic abscess and abscess anywhere in the body, there’s a general dictum for managing them – we need to drain the abscess as much as possible, as often as possible, as necessary. So we cannot always rely on antibiotics to treat abscesses; generally, regardless of size, you facilitate treatment if you drain the abscess one way or another. If you want to rely on medical treatment alone, you don’t want to drain for whatever reason there are some caveats to this. Medical therapy can be undertaken but keep in mind, about 30 percent of abscesses will eventually require drainage, a surgical drainage. So something you must tell the patient – “if we don’t operate now, we don’t drain the abscess now, in the future, about 30 percent we will have to do that. There may be some initial response with antimicrobials but eventually, we’ll have to do surgery.”
And then we need antibiotics for abscesses that are active in the medium of the abscess. You see, it’s hard to penetrate abscess, as far as antibiotics are concerned. There are few antibiotics that can do that right, like an example of that is first, clindamycin, one of our favorites in dealing with pelvic abscesses. Now again, keep in mind if you’re doing medical treatment lang, symptomatic relief, meaning the pain will go away, fever will go away, maybe you can even do microbiologic eradication, meaning kill the bacteria and maybe preserve hormonal function if the ovaries are still there. But some patients kasi, they don’t want to do surgery on them because they want to have future children, but that is not always possible, you know, when the fallopian tubes have been involved in the infection following a surgical procedure . Kunwari they removed the uterus lang, they left behind the ovaries, and etc, or they gave a myomectomy lang. Normal fertility is not always realistic, sometimes it is but not always.
And then when you manage pelvic abscesses conservatively, meaning you don’t remove the abscess or the infected issues, you’ll have to have close follow-up of the patient. Some patients kasi they don’t want to keep coming back to the doctor for checkup follow-up, etc. So if you’re dealing with such a patient you need to warn them – “you’ll have to see me every so often to check if the abscess is resolving and if it is resolved already.”
And you know, ultrasound will be very helpful in assessing the abscess. Again, if you did not remove it, you want to add antibiotics to just take care of it, you’ll have to monitor the progress of your treatment. Maybe schedule several sessions of ultrasound to monitor the abscess. Okay and then, prolong antimicrobials for abscesses not just the usual seven to 14 days, maybe you’ll have to give the antimicrobials for three, four weeks etc.
And there’s some guide as to when you can stop: 1) when the ultrasound is normal, 2) absolutely no tenderness, meaning, there is no pain when you try to examine the patient, and maybe some 3) inflammatory markers as well have returned to normal. A few more preventive measures, this is a formula for infection; so infection is related to those of microbial contamination, in other words, the amount of bacteria that are there. It is directly related.
So the higher the bacteria, the higher the chance of infection, that makes sense noh. And the virulence of the organism. Kunwari, the Staph aureus is virulent, even if it is present in low numbers, the chance of infection is still high. Unfortunately, we cannot always choose the organism involved, so we have very little control over virulence; but the dose of contamination, we can do that in terms of prevention.
So make sure it is clean; we clean, we take a bath every day. And that is inversely related to the host resistance; inversely meaning the higher the host resistance the less chance of infection and vice versa. Sometimes we can manipulate a little bit host resistance. We can tell the patient before we do surgery: control your blood sugar, etc. So microbial contamination, again, we clean the area usually with chlorhexidine, it is a good antiseptic. We ask them to take a shower, we cleanse the skin, we clip the hair right before surgery. Hindi yung shaving process kasi microtrauma and that can even predispose to a skin wound infection; so we clip instead of shave. And right before surgery, vaginal cleansing, as well, because the vaginal canal is contaminated by a lot of bacteria. So before any procedure involving the vaginal canal: CS, vaginal delivery, may be an even pelvic surgery need cleansing with an antiseptic
Prophylactic antibiotics also before surgery for certain types of surgery, like maybe CS, hysterectomy, there are recommendations to give prophylactic antibiotics; usually, a single dose right before the surgery. This is another way of reducing bacterial counts, taking out the focus of infection and in gynecology we have a lot of these – incision drainage, aspirations, maybe even taking out the uterus if it was involved after cesarean section, in severe infection.
Improving the host immune response like I mentioned already diabetes; diabetes is one immunocompromised state so if we control that sugar that will help a lot. If they’re on steroids maybe stop them for a while, if at all possible or reduce the dose. Among HIV patients, of course, you put them on antiretroviral and some lifestyle modifications; I’m sure Angel will talk a little bit more about this. Smoking is altogether a high-risk lifestyle for infection, encourage adequate sleep – seven to eight hours overnight, reduce stress – easily said but a little bit difficult, especially, in pandemic times – and promoting exercise. These are immune boosters, it is said that Vitamin C together with Zinc are good for the immune system, so sometimes maybe as preventing, as prevention, and then maybe part of treatment as well.
And some surgical techniques so I’ll just breeze through this for the benefit of our OB surgeons. So try to minimize tissue trauma, use the knife instead of extensive cauterization when you have the devitalized tissues, meaning tissues that are not viable anymore, just remove them. And when you suture, when you close, try to eliminate that space and meticulous hemostasis without compromising blood supply against a surgical technique – that will prevent infection.
And minimize leaving behind foreign bodies like sutures. If it is not necessary to suture it, don’t suture it. Don’t leave behind foreign bodies, even if it is relatively inner.
And these are specific guidelines when we do surgery: closed-drainage system. Fortunately, now in this era, we don’t use open drainage anymore. Before, during my early years, we used to do that because we didn’t have the closed-drainage system. Sentinel peritoneal packs may be helpful also – you understand what I mean by this -these are sentinel packs to protect the other part of the pelvic or abdominal cavity. Copious NSS peritoneal lavage would be helpful as well, right before closing, you don’t have to instill antibiotics in the drainage or leave behind antibiotic solutions, minimal additional benefit for that.
Open vault technique during hysterectomy, again you understand what I mean by this, pelvic surgeons except that you know this is to provide trainings as well. Closure of the fascia using Smead-Jones or
some other layered technique and hopefully, well preferably, use observable mono-filament sutures, especially, when you do episiotomy repair involving 43 lacerations.
And mass abdominal wall closure is something you must, you can consider. Also retention sutures, especially when risk for dehiscence is there. Topical antibiotic application, either in the form of solution or beads can still contribute to prevention of surgical infections. I’ll stop, I’m sorry, I took a little bit longer than my about 10 minutes. I wanted to share not only for our laypeople, perhaps in the audience, but also our colleagues in the profession. So thank you for having me participate, back to you, Apple.
DR. BANDOLA: So one of the things that’s most concerning postoperatively is the development of fever. Either they underwent a surgical procedure or they’re postpartum and right now also in the pandemic of course it’s a major concern because our patients who get admitted might also have COVID, so that’s one thing that we have to rule out. But for the purposes of this lecture, we’ll be talking about the more common post-operative or postpartum infections that cause fever. Okay, so postoperative fever is defined as a temperature of more than 38 degrees on two consecutive post-operative days or 39 degrees on any one post-operative day. Now while it occurs in 13-14 percent of patients, most cases are self-limiting. What’s quite important is that we recognize which ones would require further intervention or treatment for an underlying cause.
Now the differential diagnosis for postoperative fever is influenced by the time of onset of the fever and the most common cause of fever within the first 48 hours is a surgical response to surgery now is a physiologic response to surgery which is self-limiting. Now it’s caused by cellular injury and inflammation. So here’s a nice visual, uh table on the W’s of post-operative fever so it can be wind, caused by water, wound, walking, and wonder drugs. We’ll talk about this individually but you can see here in this table that for less than 48 hours, the more common cause of postoperative fever would be atelectasis. More than 48 hours would be pneumonia. More than 48 hours it could also be urinary tract infection. Now if you go beyond two days, you have to check the wound already or maybe consider DVT as a cause of the fever.
Now when a patient is in the hospital or immediately post-operative and they’re lying in the bed for prolonged periods, there’s incomplete expansion of the lungs and this results in atelectasis so there’s poor inspiratory effort. Syempre, if you’re in pain it’s quite difficult to be moving around and for patients who undergo intubation and general anesthesia, they may be unable to clear the pulmonary secretions. So this triggers an inflammatory response and you see that it’s quite common so we just have to make sure that we advise our patients the following. So treatment would be deep inspiration using incentive spirometry. We advise our patients early mobilization, do chest pulmonary physiotherapy and if needed, use bronchodilators. Now we want to make sure that we avoid healthcare-associated pneumonia.
Water, this pertains to urinary tract infections. It’s the most common nosocomial infection accounting for up to 40 percent of all hospital acquired infections. Now the most common risk factor that increases post-operative urinary tract infection is the placement of a urinary catheter. So symptoms of UTI would be fever and then you have to check the patients for suprapubic or flank pain, if there’s tenderness in the costovertebral angle, or if there’s urinary urgency. So what we just advise our patients is that this is easily treatable with antibiotics. Now risk factors for UTI is the length of catheterization, so we usually remove this immediately post-op, unsterile placement of the urinary catheter, a female, older age, history of diabetes, and history of previous urinary tract infections.
Now this was already discussed by Dr. Manalastas, so W for wound – surgical site infections is defined as infections that occur at or near the surgical incision within 30 days of surgery. Now the overall incidence for SSI is less than two percent and very low mortality rate. The patients would normally complain that the
wound is red, it’s warm, it’s tender, or there’s drainage from the wound and as discussed earlier, there are preventive measures pre-operatively, intraop, and post-op that can help prevent these infections. The important thing is that it’s detected early and managed early, so antibiotic treatment and if necessary, drainage to remove the focus of infection, would be the management for surgical site infections.
Walking would be DVT no so DVT in post-operative patients account for 20 percent of all hospital-acquired deep vein thrombosis. Patients at high risk for developing post-operative DVT are those who undergo abdominal pelvic surgery, those with major trauma or spinal cord injury, patients with cancer, and those who are obese can develop DVTs and as such it’s best to assess your patient pre-operatively and start prophylactic anticoagulation. Now patients with DVT present with fever after post-operative days three to five. Now for those at higher risk, the fever can occur sooner and as such it would be wise to really screen using a doppler ultrasound and start the patient with therapeutic anticoagulation when clinically safe.
Wonder drugs so this can occur anytime during the post-operative period so there are some medications which can be a common cause of non-infectious fever in post-operative patients. Now these drug related fevers are transient and require no specific treatment or work up. Now a concern for the postpartum women would also be fever so aside from the 5 Ws, it can also be caused by a peripheral infection or mastitis.
Now when we talk about the postpartum period, it begins upon delivery of the infant and the end is less well-defined. The generally accepted period would be six weeks to eight weeks however the ACOG has extended this to 12 weeks post-delivery and they actually call this the fourth trimester. So puerperal fever is temperature more than 38 degrees or higher during the puerperium. so we’ll talk about puerperal infection which is the infection of the genital tract between the onset of labor, rupture of membranes up to six weeks postpartum and this is how the patients would present. So aside from fever, there would be pelvic pain, abnormal vaginal discharge or bleeding. A foul smelling discharge would probably give us a big hint that there’s an infection in the uterus and uterine subinvolution. So the route of delivery is the single most common risk factor which is caesarean section. Causative agent it’s usually caused by a polymicrobial infection and the most common or cardinal manifestation would be fever and these patients present with fever within five days postpartum. What’s key really is early intervention as we cannot over emphasize this. So once you suspect that your patient has postpartum endometritis, IV antibiotics in the form of clindamycin with gentamicin is the preferred regimen. Now there are alternative regimen as well depending on the clinical picture of your patient and other factors. Workups would include doing a blood culture if it’s beneficial, if there’s signs of sepsis already, and of course the most important is really imaging to make sure that you’re not sitting on a pelvic abscess or a hematoma that’s infected that needs to be evacuated aside from starting antibiotic therapy. Now after starting antibiotic therapy within 24 to 48 hours, you have to reassess the patient so if they’re not getting any better then check if there’s anything else that could be causing this fever or the sepsis and consider removing the focus of infection so it may be curettage, it may be drainage, or worst-case scenario you’ll have to remove the uterus if it’s intractable sepsis already.
Now something that we always reassure, and this is something that happens to most of our patients is you know fever caused by breast engorgement so the distended breasts and high fever usually occur during the second or third day after delivery. You know we just have to advise them that they have to make sure that they remove or pump the milk out either by suckling or the breast pump to prevent progression of the disease and abscess formation. So mastitis it’s an inflammatory breast condition. It may or may not be accompanied by infection. It’s most commonly associated with lactation. So this is how our patients you know they’ll tell us, they’ll describe it but what they feel is it’s tender, it’s red, it’s swollen
and the fever is accompanied by chills no so they don’t feel well and the fever is quite high more than or equal to 38.5 degrees centigrade. Risk factors would be of course milk stasis so if it’s an inverted nipple or infrequent or missed feeding so if the baby has poor suck or if the baby is in the nursery in the NICU and cannot do direct feeding. If the moms are hesitant because the skin is already macerated or damaged, then that might cause some hesitancy in pumping or feeding on that side so there’s a preferred breast, then that can cause milk stasis. We advise our patients to wear a good fitting bra so that they wouldn’t have pressure on the breast. So lab diagnostics we don’t really need this and blood cultures are only reserved if there’s poor response to antibiotic therapy, if it’s a recurrent mastitis, and if the patient has known allergies to the usual antibiotics. Of course we also do imaging in case we want to rule out breast abscess and underlying breast abscess. So to prevent milk stasis, what’s key here is to emphasize our to our patients that we want to encourage them to have frequent and correct breastfeeding, express the milk manually to augment milk drainage. So for example, they’re really producing a lot of milk. Just store instead of wait for the baby to suck already and apply heat on the breast prior to feeding to help the letdown and cold packs to reduce the pain. Now for mild symptoms, conservative management would be ideal but if there’s no improvement within 12 to 24 hours, we may need to give antibiotics for the mastitis. So I think that’s basically it in terms of post-op and postpartum fever. We’ve discussed the causes and the general interventions to control the risk factors pre-op, intraop and post-op or postpartum for that matter and what’s important really is to identify the usual causes and intervene early to prevent morbidities. Thank you.
[LAY REACTION]
MRS. DREYFUS: Good afternoon everyone. Thank you for having me. It’s an honor to be a part of this webinar. Just to add to the wonderful introduction, I am also a wife and a mom to two bagets. My eldest is 23 years old who used to work abroad as a cabin crew in an airline company but he is here with us now due to the pandemic and my youngest naman is 19 years old and a freshman student taking up medical biology as her pre-med course. Actually, I’ve always wanted to be a cabin crew and a doctor also but I guess God has other plans for me so mga anak ko na lang magtutuloy. So for someone who is not in the medical field, I definitely learned so much from this webinar and I am sure that our audience did as well so I just want to note that during times like these when we all prefer to stay home for our safety and protection, attending webinars like this is truly a big help. The information and knowledge we have learned even while staying at home is invaluable. Malaking bagay talaga at malaking tulong sa atin. This webinar has given us much needed insight on how to prevent infections post surgery. We also learned about potential side effects, how to manage complications, possible treatments, and when to contact or seek medical assistance. It may sound simple but the truth is and in my opinion, you should give a minor infection just as much attention and care as you would a major one para hindi lumala and as mentioned by by our doctors, early intervention of any infection and close monitoring of oneself are vital to avoid major post-surgery complications. Well, it is also our best chance of recovering fast, regaining optimum health and of course, to reduce any side effects. I actually have not experienced any major surgery and my two childbirths were all normal deliveries but I made sure to follow all my doctor’s recommendations and instructions. Well, I ate healthy food and took my vitamins religiously. We know that you know post-surgery care can really be stressful lalo na sa panahon ngayon and this is where family comes in. They play an important role in one’s recovery to provide moral and physical support. Actually, my mother-in-law had breast cancer pero hindi na niya yun pinagalaw so we respected her decision but we were there to give her support, accompany her during some appointments, prepare food, and especially the much needed moral support from us. But you know there are people kasi who are living alone so maybe you can notify your closest of kin or a couple of friends so they can check up on you. You can also hire the services of a caregiver kung kaya naman and also it goes without saying that close communication with your doctor is a must. It may take long for some depending on the type of surgery
and recovery. Andiyan yung factors now of course – health condition, history, age – they all come into play so make sure you ask your doctor questions, make sure malinaw lahat, you follow your doctor’s recommendations, you take the medications as prescribed and never miss any scheduled checkups whether it’s face to face or online. Also when recovering, don’t exert yourself while in the process of recovering. It’s best to gradually return to your normal routine. Wag magmadali. Dadating din diyan eh. But if you are not recovering as well or as fast as expected, it is really best to consult your doctor right away and yun nga, I have a question na ibabato ko na rin ngayon. Given that we are going through a pandemic and all of us are afraid to go to the clinic, moreso to the hospital, are online consultations or home visits recommended?
Dr. Bandola: Yeah I think, Aileen, it’s really gonna be a hybrid when we’re doing post up or postpartum follow-up. What’s key really is having a direct line to your doctor and I think with this pandemic that has you know developed already that the doctors are more reachable. And yun nga, it’s very important – postpartum recovery. For post-op recovery, patients send pictures of their wounds, patients message if they have fever and then the basic treatment naman can be administered via telemedicine.
[QUESTION & ANSWER]
Q1: Can topical ointment be used intravaginally, for example, clotrimazole as a faster alternative to the tablet or pessary form?
A (Dr. Manalastas): Clotrimazole is not intended for intravaginal use. It’s for external use so you may use other intravaginal antimicrobial products. I’m sure there are some. Well you mentioned clotrimazole which is a generic combination drug. It’s actually more an anti-fungal. It’s actually an anti-fungal, it’s not antibacterial. If it is for a fungal infection, clotrimazole should be fine but we’re talking about bacterial surgical site infections so dequalinium chloride tablets are available so that’s the generic name you know so you may know this as fluomizin. It’s a broad spectrum antimicrobial agent, comes in tablets intended for intravaginal use so if you want, you can use that for localized infections.
Q2: Some patients only note the possible infection once they are already at home. So what are the things that we need to consider or that they should note in caring for postsurgical wound they are at home already?
A (Dr. Manalastas): First of all make sure they take a bath every day. It’s a misconception that after childbirth or after a surgery, you don’t wash the wound. You need to take a bath, wash the wound etc, wash your hands frequently. The hands are the most common way by which wounds get infected so wash your hands and then clean the wound maybe once or twice a day depending on the severity. You can use any topical antimicrobial agent like after washing, taking a bath, dry it up and then apply the antiseptic. Because very popular yung povidone iodine ngayon. It’s a little bit chemically irritating to the wound. It’s just that but it’s a good antimicrobial agent so maybe you’ll prefer chlorhexidine it’s a little less irritating to the tissues. If you ask plastic surgeons, kunyari, they never use povidone iodine on wounds kasi it causes irritation and scar formation…
Dr. Taladtad: [inaudible]
Dr. Manalastas: Yes and it’s itchy. It may be irritating. So if you want a cosmetically superior wound, try avoiding povidone-iodine. There are others. Clorhexidine is one very useful one.
Dr. Taladtad: Aside from proper hygiene…
Dr. Manalastas: Take a bath.
Dr. Taladtad: Wash your hands, take a bath.
Dr. Manalastas: Clean your wound.
Dr. Taladtad: I have a question for Dra. Bandola. Ma’am, what are the non-pharmacological ways to manage milk stasis? Is there a way to reduce pain brought by the breast engorgement?
Dr. Bandola: It’s really more of the regular emptying of the breasts. Whether it’s either direct breast feeding or pumping, that would be one way to prevent milk stasis. And then for pain, the ice packs will help relieve the engorgement or the inflammation and so that’s that’s one thing na non-pharmacologic.
Dr. Taladtad: Non-pharmacologic. So frequent emptying after tests. So how normal is postpartum fever, Ma’am? What are the warning signs that must be observed when the patient is already febrile?
Dr. Bandola: In general naman postpartum fever, we shouldn’t have this. Especially the warning signs if the patient is feeling weak, or there are chills already, or if she has accompanying symptoms like there’s a burning sensation when they’re going to urinate, or if they have cough. These are things that we really have to identify the causes so that we can manage accordingly. So in general, we shouldn’t have fever.
Dr. Taladtad: Okay, back to Sir Butch. Sir, what are the common antibiotics prescribed for post-surgical care? Or first and foremost, do we have to give antibiotics post-surgery all the time?
Dr. Manalastas: I think I mentioned that. If it’s just a superficial infection on the incision site like episiotomy, minor lang, in the abdominal wall, minor lang, usually just clean and topical antimicrobial like the ones i’ve mentioned. But if it’s having a deep or maybe even organ space, different story. Depending on the severity, oral antibiotics may be sufficient. But if it’s, according to the assessment of course of the doctor, they may have to be admitted in the hospital, given IV antibiotics. And a worse scenario is maybe even repeat surgery to take out infected tissues.
Now, you ask about common antimicrobials. Yung topical agents, we’ve discussed that already. Antimicrobial liquid, maybe even cream or ointment. Mupirocin is one of the more common ones – easily accessible. Oral agents I mentioned in one of my slides. Co-amoxiclav is one of the favorites for superficial, minor. In the deep infections, Co-amoxiclav is effective against probably the most common pathogen in skin abdominal wound infection which is Staph aureus. Now that will be active for that.
Very popular, we hear about it now. They give them amoxicillin, yung mga ganun. Unfortunately high resistance already to that. That’s why it doesn’t work. Co-amoxiclav will probably be better, but again, if it is deep or organ space, they may have to give a combination of IV antibiotics like maybe clindamycin together with gentamicin. Again, depending on the situation. But when talking about oral or IV antibiotics, dapat you consult. Hindi pwedeng – anong tawag dun? Siya lang yung patient lang. Siguro yung mga topical, yes. Mupirocin, clorhexidine, liquid. Yung mga wound care, you can do it yourself self-prescribed.
Dr. Taladtad: Sorry, I think we have to clarify also that for the antibiotics being mentioned by Dr. Butch is for infection – once there is already an infection. I think we have to use this as an opportunity for the other OBs to clarify and to remind them that we don’t need to give antibiotics for all post-operative, all postpartum patients. For example, post-NSD lang Sir, or post-cesarean section, you don’t have to give them take-home antibiotics if there is no infection. I think that’s one thing that we have to address also.
Question for Dra. Bandola. Ma’am, is it okay for a baby to continue or is it okay to continue breastfeeding even if the mother has mastitis?
Dr. Bandola: Yeah, it’s okay. I mean, we just have to make sure the breasts are always clean and that there are no abscess formation, but it’s wise to continue breastfeeding. It’s not a contraindication.
Dr. Taladtad: You also mentioned Ma’am DVT as one cause of postpartum fever. For patients who cannot walk or ambulate yet after their operation, how can we prevent DVT in these patients?
Dr. Bandola: First, if your patient is at high risk for developing DVT, you can already start your prophylaxis. But for those who cannot ambulate, there are exercises in the bed. You can have already the compression stockings and all that. It’s really more of being vigilant, being preventive, and then if it’s detected, managed immediately.
Dr. Taladtad: Thank you. For both of you, Ma’am…Sir Butch and Ma’am Angel: post surgery what are the signs and symptoms that are considered already an emergency – na hindi na pwedeng teleconsult lang?
Dr. Bandola: Ah hindi na teleconsult?
Dr. Taladtad: Yes, ma’am.
Dr. Manalastas: Angel.
Dr. Bandola: Yung highly febrile, blood pressure and weakness. It’s really more of how the whole state of the patient is. If there’s like what Dr. Manalastas said, if there’s bowel evisceration already, nandun na yung bowels. That’s really already an emergency. If there’s high grade fever that’s not responsive to initial home antibiotics, then these patients have to go to the hospital and be managed inpatient.
Dr. Taladtad: I think we have a question from the audience. This is I think for Sir Butch. Does the choice of sutures and the number of layers of sutures significantly affect the risk for surgical site infections?
Dr. Manalastas: Oh yes, certainly. The amount of foreign body especially for sutures that are non-absorbable… this stays there forever. If you put in a lot of sutures unnecessarily, they can be the nidus of infection. They’re not absorbed. They’re there always. They’re foreign body. There will be a lot of inflammation associated with that. They can be infected especially if they are near hollow organs. If you apply a suture in the vaginal cuff. Colonized yung vaginal canal. Especially if it’s polyfilament. Polyfilament there are several strands in there and there can be capillarity phenomenon. Yung bacteria from the vaginal canal can traverse the suture that you applied and stay there, in contrast to a monofilament. Monofilament is just one strand that you can just leave it if it is absorbable monofilament.
You don’t put unnecessarily. Pati yung knot tying. You put a suture and then you tie a knot. If you tie, if you throw five knots you can imagine the amount of foreign body that you leave behind instead of just two secure knots. Diba yung amount? Kung minsan that will spell the difference between a good outcome versus one that is bad outcome. Like maybe a suture granuloma that can become infected, or maybe even development of sinuses or fistulas in areas around the hollow organs. So you must be familiar. This is for our surgeons, of course. Must be familiar with your sutures and their characteristics. Huwag yung suture ka nang suture. If it’s not necessary, don’t suture kasi you’re leaving behind foreign body that can cause infection.
Dr. Taladtad: Ma’am Angel, would you like to add something?
Dr. Bandola: Oh yeah. What Sir said. Aside from that, ngayon there’s some recommendations to use antimicrobial coated sutures. Triclosan which helps also in preventing infections. If that’s available, then you can use that. You should use that.
Dr. Taladtad: Thank you, Ma’am. Ms. Aileen, you want to say something?
Ms. Aileen: I have a question pala kay Dra. Angela. Actually, she talked about UTI. I got a question sa PM ko, privately, tungkol sa UTI. A friend of mine is asking if common daw ba na lagi siyang may UTI. Parang every three months? Nag-a-antibiotics naman siya regularly, as needed.
Dr. Bandola: If it’s recurrent urinary tract infection and it’s a real UTI… Some people think it’s UTI by urinalysis lang even if asymptomatic. We may have to assess if actually each bout was really a urinary tract infection. If that’s the case, and she does have recurrent UTI, we have to investigate. We have to check if there’s an anatomical reason, meaning may problem sa kidney or sa bladder that’s causing this. We also have to assess the growth. Do a culture of the urine. Kasi baka the antibiotics given resistant na yung bacteria doon sa gamot na binibigay. We have to make sure the next medication she will receive will be the ones that would be effective or sensitive dun sa bacteria that’s growing inside.
Ms. Aileen: Okay. Thank you, Doc.
Dr. Taladtad: I think this would be our last question. For patients that we would request culture and sensitivity studies, is it necessary to do both aerobes and anaerobic cultures?
Dr. Bandola: Yeah that’s ideal. Sir, if there’s something that you need to send a culture for, especially if you’ve done like an intra-abdominal surgery, then it’s best to also get anaerobic cultures kasi you may be dealing with a polymicrobial infection.
Dr. Taladtad: Okay, Alright. I think that we conclude our open forum, I would just like to share some of the summary points I’ve noted during the lectures of Dr. Butch and Ma’am Angel. For infections after surgery
— that would be from an episiotomy or from the caesarean section wound and there could also be infections developing after a total hysterectomy. So these infections are classified based on the extent and the involvement of the disease surrounding that and the management will also depend on the extent of the infection so management would be an administration of antibiotics whether topical or systemic antibiotics and other source control procedures in some instances. Also, the most common causes of fever during the postpartum feed period are the Ws of postpartum people— which are water bin, water,wound, walking and wonder drugs, and also it’s also to emphasize that not all fever are not all febrile episodes are due to infection so we should also examine the breasts for conditions such as merciless and other breast encouragement. Okay! so that would be my summary points, and to wrap things , may we have a few points from Dr. Butch also that you would like our viewers to remember from this forum.
Dr. Manalastas: I think Lilibeth is saying that we still have a few minutes for some questions that were missed. I’m looking at our list, maybe Angel can answer this one, what size should uterine fibroids… Have you answered that?
Dr. Bandola: I was trying to answer it … So what size should they be surgically removed? Now we remove the fibroids if the patient is symptomatic, if it is causing heavy bleeding, if there’s pressure, if
there’s pain usually, if it’s quite large. May size sya na binigay, I can’t remember, 4cm? Tama ba? So it really depends on the clinical picture and if she’s not responsive to medical treatment.
Dr. Manalastas: She’s saying she’s 50 year old perimenopause
Dr. Bandola: So yeah, it really depends kunwari heavily bleeding requiring transfusion already, and not responsive to medicine. Pwede
Dr. Manalastas: So, depende talaga sa clinical symptoms ano.
Dr. Bandola: Oo, clinical talaga sya
Dr. Manalastas: What are the requirements needed before a patient can be considered ready for discharge after infection?
Dr. Bandola: Stable vital signs; has no fever; at least 24 to 48 hours na stable sya. We can discharge these patients already
Dr. Taladtad: How can we help in reducing postpartum infection during natural birth carried out by local midwives
Dr. Bandola: Sir, maybe you want to answer this question.
Dr. Manalastas: I‘m reading the questions. So, ibig sabihin … pinanganak sya sa bahay … I guess the same thing we mentioned kanina … Take a bath and make sure. For the perennial area, I guess you need to check if they did an episiotomy and a repair. So some midwives even if they’re trained they just allow it, hayaan mo na lang yan … minor lang yan … ganon. So, extra care if it is unsutured, Ii would imagine. Hindi ibig sabihin na may open wound ka, you have to take antibiotics. You have to take care locally of the area you to prevent contamination from going on. You have to eat well and rest. I think those are the things that you can do to help you can do to help. So Angel, baka gusto mo magdagdag?
Dr. Bandola: I think, of course the midwife’s naman are properly trained, but you know one thing that they found is really having adequate prenatal care screening of infections prior to um delivery is important. Advising or educating our patients on the value of of proper hygiene … i think that’s more or less what we what we can do for our patients who are handled by the midwives, and also educate the midwives to limit IEs during labor and then timely referral in case high risk ‘yung patient or matagal na nagle-labor sa kanila. We also want them to also have close coordination with their hospitals or partner obgyn nto prevent infectious morbidity in the delivery.
Dr. Taladtad: Thank you, Ma’am. For Sir Butch, Is it normal to give the patient both a system and systemic or iv and a local antibiotic.
Dr. Manalastas: Usually if they’re in the hospital that means they do have serious infection so either deep or organ space — so they’re getting IV antibiotics. Or maybe even at home, they’re given oral antibiotics.
It’s always good when you take something tapos may open wound or may wound that is infected. If iit’s just a skin or soft tissue infection, mild lang, you don’t need to give oral. But when you’re assuming you’re giving oral or maybe even IV, that means that medyo serious ‘yung infection, so you have to give
both and everything any little bit of improvement like ood diet, vitamin c, zinc — all of those little things will also contribute to resolution of the infection. So, yes, oral or maybe even IV together with wound care
— so topical antimicrobials.
Dr. Taladtad: Ma’am Angel, this is the last question for you. Should wonder drugs be avoided or is it okay to use them and then let the fever occur again and let it wear off?
Dr. Bandola: Well, when we refer to wonder drugs — it’s more like a general description. So for example, your patient is on anti-emetic medications or underwent anesthesia .. These are some medication related conditions that cause fever. So mga SSRIs have also been found to have some cross reactions. So, when we say wonder drugs, you just have to get a listing of all the medications your patients are taking and see if there’s something that could be causing the fever. Ngayon, what would be good is that you have to stop these medications or just manage it na lang and do a test also if it’s really the cause of the fever.
Dr. Taladtad: Right, I think that is our last question. To wrap things up may we have a few points Dr. Butch that you want our viewers to remember from our forum
Dr. Manalastas: Post-op infections are not just a nuisance. They can be serious also. So it takes up cooperation between not only the doctor but also the patient, and it starts with the with the pre-op preparations of patients — like correcting risk factors right before surgery and the role of the surgeon at the time of surgery and the role of the patient after.
So cooperation during all those times will prevent infection, and if they occur if they occur sometimes, you cannot help they occur from anyone anywhere from 1-3% no matter what you do. But most of the time if they occur after preparing the patient very well doing the surgery very well, they’re usually mild manageable and no serious consequence.
Dr. Taladtad: Thank you sir and a few reminders from you, Dr. Bandola?
Dr. Bandola: Well, it’s just really about mitigating the the factors that could cause infections pre-op and addressing these infections early on to prevent it to from getting worse. So it’s really more of collaboration and vigilance in terms of making sure that these issues are addressed early.
Dr. Taladtad: Thank you, Ma’am. You want to add something Ma’am Yen?
Ms. Dreyfus: Just like what Dr butch said, patients cooperation is really important so when you’re feeling something after surgery, you consult your doctor right away so that these concerns can be addressed asap because you know the longer we wait the bigger the risk and our health should be our top priority because health is wealth.
Dr. Taladtad: Thank you, thank you again! Our sincere gratitude to our speakers for giving everyone an informative overview on managing and preventing post-surgical infectious complications by giving importance on the post-surgery care.
