Emerging problems in gram-positive infections in the postoperative patient

Gram-positive bacteria are increasingly prevalent in the postoperative patient population and are important as pathogens. As increasingly ill and elderly patients undergo surgical treatment and as increased use is made of invasive or immunosuppressive treatment modalities, this trend is likely to accelerate. The increasing use of broad-spectrum antibiotics results in the emergence of resistant pathogens or superinfections that are increasingly difficult to treat. Examples of such pathogens include methicillin-resistant Staphylococcus epidermidis, vancomycin-resistant enterococci and Clostridium difficile. No acute care setting, from large urban teaching hospital to small rural community hospital, is immune to the trend. The clinical challenge posed by these organisms is compounded by the fact that serious gram-positive infections can be impossible to distinguish on clinical grounds from their gram-negative counterparts. The host inflammatory response to gram-positive infection is quite similar to that caused by gram-negative infection, including elaboration of cytokine mediators and progression to visceral organ dysfunction. The clinician must be cognizant that serious infections, especially of nosocomial origin, may be caused by gram-positive bacteria.