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Infectious complications related to regional anesthesia are rare. Since the only information is available in case reports and retrospective surveys, it is likely that these complications are underreported. The objective of this chapter is to summarize information from the literature on infections associated with regional anesthesia, as well as to discuss the mechanism and to suggest strategies to prevent these complications.

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Microorganisms from exogenous or endogenous sources may gain access to the subarachnoid, epidural, or tissue space surrounding peripheral nerves in several ways. Microorganisms from the patient's or anesthesia practitioner's flora can be inoculated directly when a catheter or needle is inserted into those spaces. Several reports in the literature suggest that infections are on occasion caused by the anesthesia practitioner's flora.1–3 For example, Trautmann and colleagues reported a case of meningitis caused by a Staphylococcus aureus strain that was identical by pulsed-field gel electrophoresis to the S. aureus isolate from the anesthesiologist's nose.2 Microorganisms can also enter the epidural space by hematogenous spread from other body sites, such as infected skin,2,4 or by migrating along the catheter tract.5,6 Several case reports suggested that infection was caused by spread of bacteria from infected sites through the bloodstream to the epidural space.7–9 Others maintain that infections at distal sites are not contraindications to epidural anesthesia. For example, Newman concluded that distal infections did not increase the risk of epidural infection because traumatic injuries are often infected and no epidural catheter-related infections were identified among over 3000 patients who had epidural neural blockades for postoperative or posttraumatic analgesia.10 The anesthetic agents injected into the patient's subarachnoid or epidural space are another possible source of infection. Infections from contaminated multidose vials are likely to be rare because most anesthetic drugs are weak bases dissolved in acidic solutions that inhibit growth of bacteria and fungi11–13; besides most multidose local anesthetic solutions contain a bacteriostatic agent. Nevertheless, the case report by North and Brophy suggests that contaminated multidose vials still can be a source of infection. These authors reported an infection in which S. aureus isolates with matching phage types were recovered from an abscess and a multidose lidocaine vial.1

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Clinical Pearls
  • Streptococcal species, S. aureus, and Pseudomonas aeruginosa are the most common causative agents.
  • Microorganisms from the patient's or anesthesia practitioner's flora can be inoculated directly when a catheter or needle is inserted into the epidural or subarachnoid space.
  • Because it is easy to contaminate the needle or the catheters, anesthesiologists must strictly adhere to hygienic measures.
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To assess whether contamination of the anesthetic agent or the equipment (needles, syringes, tubing) is related to subsequent infections, investigators have cultured these items after they have been used with patients or during simulations. In four studies, 0–29% of used catheters were contaminated,14–17 and James and coworkers found that 5 of 101 syringes used ...

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