1 Sepsis is both the presence of infection and the host response to infection (systemic

inflammatory response syndrome, SIRS). Sepsis is a clinical spectrum, ranging from sepsis (SIRS
plus infection) to severe sepsis (organ dysfunction), to septic shock (hypotension requiring
vasopressors). Outcomes in patients with sepsis are improved with an organized approach to
therapy that includes rapid resuscitation, antibiotics, and source control.
2 Source control is a key concept in the treatment of most surgically relevant infections. Infected
or necrotic material must be drained or removed as part of the treatment plan in this setting. Delays
In adequate source control are associated with worsened outcomes.
3 Principles relevant to appropriate antibiotic prophylaxis for surgery: (a) select an agent with
activity against organisms commonly found at the site of surgery, (b) the initial dose of the
antibiotic should be given within 30 minutes prior to the creation of the incision, (c) the antibiotic
should be redosed during long operations based upon the half-life of the agent to ensure adequate
tissue levels, and (d) the antibiotic regimen should not be continued for more than 24 hours after
surgery for routine prophylaxis.
4 When using antimicrobial agents for therapy of serious infection, several principles should be
followed: (a) identify likely sources of infection, (b) select an agent (or agents) that will have
efficacy against likely organisms for these sources, (c) inadequate or delayed antibiotic therapy
results in increased mortality, so it is important to begin therapy rapidly with broader coverage,
(d) when possible, obtain cultures early and use results to refine therapy, (e) if no infection is
identified after 3 days, strongly consider discontinuation of antibiotics, based upon the patient’s
clinical course, (f) discontinue antibiotics after an appropriate course of therapy.
5 The incidence of surgical site infections can be reduced by appropriate patient preparation,
timely perioperative antibiotic administration, maintenance of perioperative normothermia and
normoglycemia, and appropriate wound management.
6 The keys to good outcomes in patients with necrotizing soft tissue infection are early recognition
and appropriate debridement of infected tissue with repeated debridement until no further signs of
infection are present.
7 Transmission of HIV and other infections spread by blood and body fluid from patient to health
care worker can be minimized by observation of universal precautions, which include routine use
of barriers when anticipating contact with blood or body fluids, washing of hands and other skin
surfaces immediately after contact with blood or body fluids, and careful handling and disposal of
sharp instruments during and after use.

Infection is defined by the presence of microorganisms in host tissue or the bloodstream. At the
site of infection the classic findings of rubor, calor, and dolor in areas such as the skin or
subcutaneous tissue are common. Most infections in normal individuals with intact host defenses
are associated with these local manifestations, plus systemic manifestations such as elevated
temperature, elevated white blood cell (WBC) count, tachycardia, or tachypnea. The systemic
manifestations noted previously comprise the systemic inflammatory response syndrome (SIRS).
A documented or suspected infection with some of the findings of SIRS define sepsis. SIRS can
be caused by a variety of disease processes, including pancreatitis, polytrauma, malignancy,
transfusion reaction, as well as infection (Fig. 6-1). There are a variety of systemic manifestations
of infection, with the classic factors of fever, tachycardia, and tachypnea, broadened to include a
variety of other variables (Table 6-1). Sepsis (SIRS caused by infection) is mediated by the
production of a cascade of proinflammatory mediators produced in response to exposure to
microbial products. These products include lipopolysaccharide (endotoxin, LPS) derived from
Gram-negative organisms; peptidoglycans and teichoic acids from gram-positive organisms; many
different microbial cell wall components, such as mannan from yeast and fungi; and many others.

Severe sepsis is characterized as sepsis (defined previously) combined with the presence of new-
onset organ failure. Severe sepsis is the most common cause of death in noncoronary critical care
units and the 11th most common cause of death overall in the United States, with a mortality rate
of 10.3 cases/100,000 population in 2010. A number of organ dysfunction scoring systems have
been described. With respect to clinical criteria, a patient with sepsis and the need for ventilatory
support, with oliguria unresponsive to aggressive fluid resuscitation, or with hypotension requiring
vasopressors should be considered to have developed severe sepsis. Septic shock is a state of acute
circulatory failure identified by the presence of persistent arterial hypotension (systolic blood
pressure <90 mm Hg) despite adequate fluid resuscitation, with- out other identifiable causes.
Septic shock is the most severe manifestation of infection, occurring in approximately 40% of
patients with severe sepsis; it has an attendant mortality rate of 30% to 66%.