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Open Access This chapter is licensed under the terms of the Creative Commons Attribution-
NonCommercial- NoDerivatives 4.0 International License (http://creativecommons.org/licenses/
by- nc- nd/4.0/), which permits any noncommercial use, sharing, distribution and reproduction in
any medium or format, as long as you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons license and indicate if you modied the licensed
material. You do not have permission under this license to share adapted material derived from this
chapter or parts of it.
The images or other third party material in this chapter are included in the chapter's Creative
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included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
A. Oliva and M. Venditti
Source Control
https://t.me/med1917
14
SilviaStrambi, CamillaCremonini, DarioTartaglia,
MassimoChiarugi, andFedericoCoccolini
14.1 Definition
The term “source control” (SC) refers to any intervention aimed at identifying and
eliminating (or controlling) the source of infection within the abdomen to restore
normal homeostasis [1]. Combined with targeted antibiotic therapy, SC is crucial in
the management of intra-abdominal infections (IAIs) [2].
Nowadays, SC is no longer only a surgical concern, but it advocates a multidisciplinary and multimodal approach. A better understanding of sepsis, from its
pathophysiological basis to the systemic effects and impact on the human microbiome, implies that SC is a complex concept that encompasses various factors. These
include the underlying causative event, the responsible bacteria, the local environment, the overall condition of the patients, and any comorbidities they may have.
The primary objective of SC is to remove or drain the infected material to ensure
cessation of the ongoing contamination and further spreading of infection [3].
Moreover, SC aims to manage the production and spread of systemic mediators and
the disruptive effects on the microbiome that contribute to multiple organ failure
and potentially fatal outcomes.
Despite a good understanding of its complexity, there is currently no conclusive
denition of the operative technique, optimal timing, or adequacy of SC, and the
morbidity and mortality rates remain high [1].
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 60462- 1_14.
S. Strambi · C. Cremonini · D. Tartaglia · M. Chiarugi · F. Coccolini (*)
General, Emergency and Trauma Surgery Department,
Pisa University Hospital, Pisa, Italy
e-mail: silvia.strambi@phd.unipi.it; c.cremonini89@gmail.com;
dario.tartaglia@unipi.it; massimo.chiarugi@unipi.it; federico.coccolini@unipi.it
© The Author(s) 2025
S. Bartoli et al. (eds.), Infections in Surgery, Updates in Surgery,
https://doi.org/10.1007/978-3-031-60462-1_14
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S. Strambi et al.
14.2 Patient Stratification
A proper SC cannot disregard the patient’s current physiological condition, medical
history, and home therapy. Additionally, the specic source of infection and its clinical severity are dynamic variables that inuence the therapeutic strategy. It is therefore evident that SC requires a highly personalized approach. Hence, an initial
assessment of the patient based on these variables (physiological condition, comorbidities, medications, immunological status) takes priority.
The WSES Sepsis Severity Score [4] is an easy-to-calculate and specic score
for complicated IAIs, which takes into account clinical condition on admission, setting of acquisition, anatomical origin of the IAI, delay in SC and general risk factors
(age >70years, chronic glucocorticoids, immunosuppressant agents, chemotherapy,
lymphatic diseases, virus). It represents a useful tool to modulate the extent of SC
especially in high-risk patients [4]. The “high-risk” denition is generally used to
describe patients with a high probability of treatment failure and mortality.
According to Coccolini etal. [5], patients can more specically be stratied into
three groups:
• Class A
• Healthy patients with no or well-controlled comorbidities and no immunocom-
promise, where the infection is the main problem.
• Class B
• Patients with major comorbidities and/or moderate immunocompromise but cur-
rently clinically stable, in whom the infection can rapidly worsen the prognosis.
• Class C
• Patients with important comorbidities in advanced stages and/or severe immuno-
compromise, in whom the infection worsens an already severe clinical condition.
In immunocompromised patients, either for congenital or acquired conditions [6, 7]
or in the so-called “high-risk patients”, it is essential that the evaluation is carried
out not only by the surgeon but by a multidisciplinary team, which includes the
emergency physician, the anesthesiologist, and the infectious disease specialist, as
well as any other specialist consultants depending on the specic pathologies to be
evaluated. Once the assessment has been completed, it is the surgeon that has the
nal responsibility in the decision-making process and who proceeds with SC, if
indicated.
14.3 Timing andPriorities
Despite the general agreement to start “as soon as possible”, especially in the critically ill patient, to date there is no clear consensus about the timing of SC [1].
Moreover, owing to the need for a tailored approach, general evidence cannot be
uniformly applied. There are multiple published indications available, but they lack
standardization and the proposed timings for SC vary. It has been proposed that SC
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119
should be carried out immediately or “as soon as possible” in patients with severe
IAIs, while delayed SC up to 7–24 h after diagnosis has been reported for IAIs
without signs of systemic inammation [2].
The 2017 Surgical Infection Society revised guidelines indicated that SC interventions must be undertaken within 24h from IAI diagnosis, except when clinical
evidence suggests as appropriate a non-interventional or delayed approach (strength
of the recommendations: Grade 2-B), whereas a more urgent intervention is warranted in cases of sepsis or septic shock (strength of the recommendations: Grade
2-C) [8]. The guidelines from the Surviving Sepsis Campaign for the Management
of Sepsis and Septic Shock recommend promptly determining the anatomical site of
infection requiring urgent SC in patients with sepsis or septic shock. They also suggest implementing the necessary SC intervention as soon as it is medically and
logistically feasible after the diagnosis is established [1]. The concern previously
raised in the literature regarding a possible benecial effect of delayed treatment in
favor of an initial phase of resuscitation and optimization has now been overcome
[9–11]. Recent studies on gastrointestinal perforations have conrmed the need for
timely treatment, as delays of only 3–6h were associated with an increase in mortality [1, 12–14]. Boyd-Carson etal. [15] observed that each additional hour of delay
of the operative SC caused a 6% increase in mortality and that mortality in patients
treated within 6h was 18% higher than in those treated within the rst hour.
The level of urgency of treatment is determined by the site and spread of infection (localized vs. generalized), its rate of progression, and the underlying clinical
condition of the patient. Hence, three main situations of SC urgency can be identied [5]:
• Emergent source control
• For patients at high risk of mortality due to a severe physiological disturbance
caused by the acute disease, emergent SC is necessary and must be initiated as
soon as there is strong suspicion or conrmation of the diagnosis.
• Urgent source control
• In cases where SC is a critical aspect of infection treatment, it is generally accept-
able to delay the intervention for 1–24h to improve the patient’s clinical condi-
tion through adequate uid resuscitation and broad-spectrum antibiotic therapy.
• Delayed source control
• SC may be delayed in patients for whom it may be appropriate to wait until the
infectious process is clearly delineated, reducing the risks of unintended surgical
damage to adjacent tissues.
Any additional SC intervention over the rst can be either planned at the time of the
initial procedure or decided based on the clinical, laboratory and diagnostic postintervention examinations (“on demand”). Scheduled relaparotomies involve serial
surgical revisions every 48–72h until the abdomen is macroscopically clean, regardless of the patient’s clinical status. Their advantages would be the early identication of any residual or recurrent collections and a reduction of the potential risk of
gastrointestinal stulas and delayed hernias. However, this approach comes at the
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cost of a large number of unnecessary laparotomies [1, 16]. Moreover, additional
lavage treatment was demonstrated to have an amplifying effect on the systemic
inammatory mediators (especially IL-8), possibly leading to further organ disfunction [16, 17]. A large 2007 Dutch randomized clinical trial showed positive clinical
and economic effects of the on-demand strategy, compared to planned relaparotomy. They observed signicantly shorter ICU and median length of hospital stay
(p= 0.001) combined with a decrease in the rate of relaparotomies and medical
costs, with no difference in death or major peritonitis-related morbidity rates [16,
18]. Despite these ndings, planned relaparotomies are currently performed. Current
evidence suggests the “on demand” strategy as the gold standard in the SC process,
based on a careful follow-up with an accurate surveillance algorithm [8].
S. Strambi et al.
14.4 Adequacy
There is no universally recognized denition of adequate SC.Adequacy of SC is a
broad concept that involves several interrelated requirements, both anatomical and
physiological: prompt identication of the site of origin (due to different bacterial
ora), gross decontamination (either surgical or not), resolution of the source of
infection, proper administration of antibiotics, support of vital functions, and elimination of systemic inammatory response mediators and toxins [5].
An adequate anatomical and physiological SC must encompass interconnected
and combined actions and interventions including [5]:
– antibiotic/anti-infective therapy;
– surgery;
– minimally invasive non-surgical/radiological procedures;
– physiological support and restoration aiming to reduce the disease burden.
Although the treatment varies according to the specic underlying pathology and
the patient’s clinical condition, a surgical SC associated with short-course antibiotic
therapy can be considered sufcient in uncomplicated forms. Otherwise, it could be
necessary to extend the duration of antibiotic treatment and physiological support
strategies based on the clinical evolution. In severe forms of IAI or in critically ill
patients the surgical strategy may involve multiple repeated procedures, until resolution of the infection [5]. In this sense, it may be useful to employ a damage control
surgery strategy that provides for the temporary closure of the abdomen associated,
if feasible, with a negative pressure wound therapy (NPWT) device [1]. This is particularly indicated to avoid the risk of abdominal compartmental syndrome (ACS)
in the presence of intra-abdominal hypertension, to complete SC in persistent infection and to reassess intestinal perfusion in doubtful cases of mesenteric ischemia
[8]. Other authors instead underline the risks of leaving open an abdomen which
could theoretically be closed, as they argue that ACS in the case of non-traumatic
sepsis can be prevented by optimizing medical therapy and that open abdomen
increases the risk of uid and electrolyte imbalances and gastrointestinal stula [1].
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121
To understand if the open abdomen with NPWT could play a role in improving the
clearance of inammatory mediators in patients, we have to await the results of
prospectively randomized trials, such as the COOL Trial [19, 20]. Moreover, the
adequacy of SC is also related to the treatment setting, the technologies available in
the hospital and the surgeon’s skills [2, 5].
14.5 Specific Intra-Abdominal Infections
Figures showing the operative procedures and need for antibiotic therapy based on
the patient’s classication and urgency level of SC for the main signicant sources
of IAI (acute cholecystitis, acute cholangitis, acute appendicitis, acute left colonic
diverticulitis, acute right colonic diverticulitis, small bowel perforation, gastroduodenal ulcer perforation, post-traumatic perforation, and acute pancreatitis) [5] are
provided in the online Supplementary material of this chapter.
References
1. Sartelli M, Coccolini F, Kluger Y, etal. WSES/GAIS/SIS-E/WSIS/AAST global clinical pathways for patients with intra-abdominal infections. World J Emerg Surg. 2021;16(1):49.
2. Schena CA, de’Angelis GL, Carra MC, etal. Antimicrobial challenge in acute care surgery.
Antibiotics (Basel). 2022;11(10):1315.
3. Marshall JC, al Naqbi A.Principles of source control in the management of sepsis. Crit Care
Clin. 2009;25(4):753–68, viii–ix.
4. Sartelli M, Abu-Zidan FM, Catena F, et al. Global validation of the WSES Sepsis Severity
Score for patients with complicated intra-abdominal infections: a prospective multicentre
study (WISS study). World J Emerg Surg. 2015;10:61.
5. Coccolini F, Sartelli M, Sawyer R, etal. Source control in emergency general surgery: WSES,
GAIS, SIS-E, SIS-A guidelines. World J Emerg Surg. 2023;18(1):41.
6. Coccolini F, Improta M, Sartelli M, etal. Acute abdomen in the immunocompromised patient:
WSES, SIS-E, WSIS, AAST, and GAIS guidelines. World J Emerg Surg. 2021;16(1):40.
7. Coccolini F, Improta M, Cicuttin E, etal. Surgical site infection prevention and management
in immunocompromised patients: a systematic review of the literature. World J Emerg Surg.
2021;16(1):33.
8. Mazuski JE, Tessier JM, May AK, etal. The Surgical Infection Society revised guidelines on
the management of intra-abdominal infection. Surg Infect (Larchmt). 2017;18(1):1–76.
9. Sethi A, Debbarma M, Narang N, etal. Impact of targeted preoperative optimization on clinical outcome in emergency abdominal surgeries: a prospective randomized trial. Anesth Essays
Res. 2018;12(1):149–54.
10. Coccolini F, Sartelli M, Catena F, etal. Early goal-directed treatment versus standard care in
management of early septic shock: meta-analysis of randomized trials. J Trauma Acute Care
Surg. 2016;81(5):971–8.
11. Azuhata T, Kinoshita K, Kawano D, etal. Time from admission to initiation of surgery for
source control is a critical determinant of survival in patients with gastrointestinal perforation
with associated septic shock. Crit Care. 2014;18(3):R87.
12. Bloos F, Thomas-Rüddel D, Rüddel H, etal. Impact of compliance with infection management
guidelines on outcome in patients with severe sepsis: a prospective observational multi-center
study. Crit Care. 2014;18(2):R42.
13. De Waele JJ.Early source control in sepsis. Langenbecks Arch Surg. 2010;395(5):489–94.
122
https://t.me/med1917
14. Hecker A, Schneck E, Röhrig R, etal. The impact of early surgical intervention in free intestinal perforation: a time-to-intervention pilot study. World J Emerg Surg. 2015;10:54.
15. Boyd-Carson H, Doleman B, Cromwell D, etal. Delay in source control in perforated peptic
ulcer leads to 6% increased risk of death per hour: a nationwide cohort study. World J Surg.
2020;44(3):869–75.
16. van Ruler O, Boermeester MA.Surgical treatment of secondary peritonitis: a continuing problem. Chirurg. 2017;88(Suppl 1):1–6.
17. Zügel N, Siebeck M, Geissler B, etal. Circulating mediators and organ function in patients
undergoing planned relaparotomy vs conventional surgical therapy in severe secondary peritonitis. Arch Surg. 2002;137(5):590–9.
18. van Ruler O, Mahler CW, Boer KR, etal. Comparison of on-demand vs planned relaparotomy
strategy in patients with severe peritonitis: a randomized trial. JAMA. 2007;298(8):865–72.
19. Kirkpatrick AW, Coccolini F, Ansaloni L, etal. Closed or open after source control laparotomy
for severe complicated intra-abdominal sepsis (the COOL trial): study protocol for a randomized controlled trial. World J Emerg Surg. 2018;13:26.
20. Kirkpatrick AW, Coccolini F, Tolonen M, etal. The unrestricted global effort to complete the
COOL trial. World J Emerg Surg. 2023;18(1):33.
S. Strambi et al.
Open Access This chapter is licensed under the terms of the Creative Commons Attribution-
NonCommercial- NoDerivatives 4.0 International License (http://creativecommons.org/licenses/
by- nc- nd/4.0/), which permits any noncommercial use, sharing, distribution and reproduction in
any medium or format, as long as you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons license and indicate if you modied the licensed
material. You do not have permission under this license to share adapted material derived from this
chapter or parts of it.
The images or other third party material in this chapter are included in the chapter's Creative
Commons license, unless indicated otherwise in a credit line to the material. If material is not
included in the chapter's Creative Commons license and your intended use is not permitted by
statutory regulation or exceeds the permitted use, you will need to obtain permission directly from
the copyright holder.
Infection Control inProsthetic Surgery
https://t.me/med1917
15
GiuliaIanni, FrancescoPizza, AndreaSiani,
TommasoCastrucci, FedericoAccrocca,
andStefanoBartoli
15.1 Introduction
Surgical site infections (SSI) occur in all surgical specialties with an incidence of
2–5% for class 1–2 clean procedures, and account for approximately 38% of all
nosocomial infections related to surgery. Higher rates are reported in traumatic injuries (20–50%), in specic conditions, or in patients undergoing high-risk vascular
surgery (15% or higher). SSI signicantly increase both costs and morbidity, especially when prosthetic material is used [1]. Indeed, in the last two decades, although
the advent of endovascular procedures in selected cases would seem to have
improved outcomes, graft infection still remains one of the most important adverse
events (0.5–5%) and a serious health problem [2]. Mesh infections in ventral hernia
repair result in reoperations in 5–10% of cases, leading to longer hospital stays and
higher healthcare costs [3].
15.2 Pathogenesis
The pathobiology of SSI is best understood if it is classied as an infection mediated by pathogenic strains that grow and develop by creating a barrier called a “biolm” [4]. The matrix constituting the biolm is composed of extracellular polymeric
substance (EPS) produced by bacteria and their degradation in contact with the host
organism. The bacteria adhere to the prosthetic material forming microcolonies in
G. Ianni (*) · A. Siani · T. Castrucci · F. Accrocca · S. Bartoli
Department of Vascular Surgery, Sant’Eugenio Hospital-ASL Roma 2, Rome, Italy
e-mail: giuliaianni@hotmail.com; andreasiani@yahoo.it; tcastrucci@gmail.com;
federico.accrocca@aslroma2.it; steba08@gmail.com
F. Pizza
A.Rizzoli Hospital, ASL Napoli 2 Nord, Naples, Italy
e-mail: francesco_pizza@libero.it
© The Author(s) 2025
S. Bartoli et al. (eds.), Infections in Surgery, Updates in Surgery,
https://doi.org/10.1007/978-3-031-60462-1_15
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G. Ianni et al.
which the production of EPS begins; this represents a stable and safe environment
in which they live and communicate with each other (quorum sensing mechanism).
In this matrix, the bacteria show a low level of both activity and growth, and this
explains their high resistance to the host defenses and low sensitivity to antibiotics
[4, 5]. The bacterial biolm is able to colonize potentially all prosthetic surfaces
such as heart valves, vascular and orthopedic prostheses and intravenous catheters.
According to the National Institutes of Health, it is estimated that 65% of soft tissue,
respiratory and urinary tract infections are caused in part by biolm-producing bacteria [5]. Bacterial adhesion to the prosthetic device is promoted by the uid proteins present in both the blood and tissues of the host organism, by the characteristics
of the prosthetic surface and by the intrinsic properties of the bacterium; in
Staphylococcus spp., for example, the adhesion process is controlled by specic
genes which code for extracellular adhesion proteins. Biolm formation can occur
either by direct contamination or by transient bacteremia. The biolm formation
process involves four stages: (1) adhesion; (2) aggregation and accumulation of
EPS; (3) maturation; and (4) detachment.
During the last stage (planktonic phase), the bacteria start to form a new biolm
on a distant surface within the host, thus spreading the infection. The most important aspect that characterizes biolm is resistance to antibiotic agents. Indeed, antimicrobial agents have greater difculty penetrating the biolm because of both the
action of the mechanical barrier and the reduced metabolic activity of the bacteria.
Some substances such as lactoferrin (chelating iron), N-acetyl cysteine, silver and
some antibiotics (rifampicin, macrolides, azithromycin) are able to interfere with
the production of biolms by preventing the nutrition of the bacteria themselves and
inhibiting the production of the EPS and communication between cells (quorum
sensing inhibitor) [6].
Several studies have been carried out to evaluate the biocompatibility and resistance to infections of prostheses used vascular surgery. Polyethylene terephthalate
(Dacron) and polytetrauoroethylene (PTFE), known as Gore-Tex, are the most
commonly used synthetic grafts in vascular surgery. Dacron prostheses have two
different textures (woven and knitted) that lead to different permeability, compliance and tissue integration, exposing to a greater risk of infection. The PTFE molecule is biologically stable and, due its electronegative surface, the interaction of
blood cells with the prosthesis is minimal, making it more resistant to germs [7].
Many tools have been investigated to prevent or solve the infection, such as the use
of antibiotic beads. Initially used to combat possible infections associated with
emergency orthopedic surgery and in osteomyelitis, they were subsequently used in
prosthetic infections in the vascular eld.
Even in abdominal wall surgery the choice of prosthetic materials can make a
signicant difference.
Synthetic meshes—e.g., made of heavyweight polypropylene (PP), PTFE, combinations of PTFE/PP, PP covered with omega-3 fatty acids (C-QUR mesh), and
multilament polyester—facilitate the formation of biolm leading to both acute
and chronic recurrent infections requiring removal of the mesh. Biological or
15 Infection Control inProsthetic Surgery
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biosynthetic meshes, although more expensive, have been associated with lower
rates of mesh infection, between 1.5% and 10.9% [8].
Unlike powders, pastes and sponges, antibiotic beads have greater stability over
time and therefore the release of antibiotic molecules is more lasting. At rst, a sort
of bone cement (polymethylmethacrylate, PMMA) was used, which was mixed
with antibiotic powder and shaped in non-absorbable beads and then either left
indenitely or removed in a later surgical procedure. Subsequently, biodegradable
formulations based on calcium sulphate (CaSO4) were used, formulations which
dissolve after months, releasing a high antibiotic concentration [1]. With the use of
antimicrobial prostheses, the infection will only occur if the bacteria that approach
the prosthetic surface are able to adhere to it and become metabolically active. By
far the most frequently used are silver prostheses. The antimicrobial efcacy of
silver is attributed to a series of mechanisms including the binding to membrane
phospholipids which interferes with membrane transport and effectively closes the
cell pump mechanism necessary for bacterial cell viability [9].
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15.3 Bacteriology
Although any microorganism could potentially be responsible for a prosthetic infection, Staphylococcus aureus is involved in approximately 80% of cases of vascular
graft, orthopedic or cardiac prosthesis infection, with an approximately four-fold
increase in recent decades of methicillin-resistant S. aureus (MRSA). Infection can
be caused by both Gram-positive and Gram-negative strains; the most frequently
found germs are Staphylococci (S. aureus and S. epidermidis), Streptococci,
Enterococci, Escherichia coli, Klebsiella pneumoniae, Enterobacterales,
Pseudomonas spp., and Candida albicans [10]. Staphylococci and Pseudomonas
spp. are strong biolm producers. S. aureus, in particular, is a microorganism capable of surviving in highly unfavorable conditions by colonizing the mucous membranes (e.g., the nasal mucosae) and the skin, causing serious pyogenic infections
and worse SSI outcomes [11].
15.4 Classification
Depending on the onset, prosthetic infections are classied into early and late. Early
infections develop within 3months from surgery, and manifest with fever, bacteremia, pain, bleeding, erythema and purulent secretion from the surgical site and, in
vascular surgery, with graft occlusion or formation of pseudoaneurysms. They are
generally due to virulent microorganisms such as S. aureus, E. coli, Klebsiella spp.,
Pseudomonas spp. or other Gram-negative species that spread rapidly and can cause
tissue necrosis and rupture of the anastomosis. Late infections develop several
months after surgery and can result from a local infection involving the prosthesis
or from bacteremia; they generally have milder symptoms, few systemic
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