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1Sarah and Harold Lincoln Thompson Professor of Surgery University of Chicago, 5841 S Maryland MC 6090, Chicago, Illinois 60637.
Abstract:
Despite major advances in infection control and the ever increasing use of broader spectrum antibiotics in surgery, postoperative infections continue to occur under the best of care and in the best institutions. Postoperative infections, also termed "surgical site infections (SSIs), can range from superficial wound infections to deep organ space infections. SSIs can be superficial and only require medical treatment (i.e antibiotics), whereas others such as deep organ space infections resulting from an anastomotic leak can require multiple surgeries leading to sepsis and occasionally shock and death. Many if not most stakeholders in the field including surgeons, infectious disease specialists, infection control nurses, etc., in general advocate the use of prophylactic antibiotics and the enforcement of greater levels of sterility reasoning that all postoperative infections must arise from some type of direct contamination event. In this piece, the alternative view is presented that today, in the era of mandated asepsis protocols, enhanced recovery programs, and enforcement of prophylactic antibiotics in all cases, many if not most postoperative infections and SSIs occur from pathogens endogenous to the patient not from sources exogenous to the patient. It is also suggested that applying broader antibiotic coverage in elective surgery is neither an evolutionarily stable strategy nor inexorable in the context of emerging knowledge in the field of gut ecology. Here this concept is reviewed and the rationale behind using agents that preserve the gut microbiome and attenuate pathogen virulence in lieu of applying broader spectrum antibiotics and greater levels of sterility.
Insights
Surgical site infections (SSIs) may stem from the patient's own bacteria, not external contamination. Preserving gut health with targeted therapies could be more effective than broad-spectrum antibiotics for preventing postoperative infections.
Area of Science:
- Infectious Diseases
- Surgical Site Infections (SSIs)
- Microbiome Research
Background:
- Postoperative infections, or surgical site infections (SSIs), remain a challenge despite advances in infection control and antibiotic use.
- Current strategies often focus on external contamination, advocating prophylactic antibiotics and strict sterility.
- SSIs range from superficial to deep organ space infections, with severe cases leading to sepsis and mortality.
Purpose of the Study:
- To present an alternative perspective on the origins of postoperative infections and surgical site infections (SSIs).
- To challenge the prevailing view that SSIs primarily arise from exogenous contamination.
- To explore the role of endogenous pathogens and gut ecology in SSIs.
Main Methods:
- Review of current practices in infection control and antibiotic prophylaxis in surgery.
- Conceptual review of the endogenous vs. exogenous sources of surgical site infections (SSIs).
- Discussion of the implications of gut ecology on postoperative infection development.
Main Results:
- Proposes that many postoperative infections and SSIs may originate from the patient's endogenous pathogens, particularly in the context of modern aseptic protocols.
- Questions the evolutionary stability and necessity of broad-spectrum antibiotic use in elective surgery.
- Highlights the potential impact of gut microbiome disruption on SSI development.
Conclusions:
- Suggests that endogenous pathogens play a significant role in postoperative infections and surgical site infections (SSIs).
- Advocates for strategies that preserve the gut microbiome and attenuate pathogen virulence over broad-spectrum antibiotics.
- Calls for a re-evaluation of current approaches to preventing SSIs, considering gut ecology.
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