Surgical Infections

Vichram S Paulraj
Maheswaran Muthumanickam
Presenters : Shyama Vishwambaran
Gowri Pukazhanthi
 Definition

Infection :
Invasion of microorganism to the healthy
tissue producing inflammatory reaction
 Pathogenesis and bacteriology

Microorganisms usually prevented from causing

infection in tissues by intact epithelial surface,
mainly the skin.
Protective mechanism includes:
1- Chemicals: low PH gastric juice.
2- Humoral: antibodies, complements and opsonin.
3- Cellular: phagocytic cells, macrophages,
polymorphnuclear cells and killer lymphocytes.
 Diagnosis

1-History
2-Clinical examination
Clinical features of acute
inflammation :
calor(heat) +rubber (redness),
dolour (pain)+ tumour
(swelling) + function laesa
(loss/impairment of
function)
3-Laboratory investigation /
Radiology imaging.
 Surgical Infections
Two main types

1. Community-Acquired
Are active process that were initiated
before the patient presented for
treatment
2. Hospital-Acquired
All infections that occur after
surgical procedures
 Community-Acquired

Skin/soft tissue

Cellulitis: Group A strep

Tetanus
Abcess/furuncle: Staph
aureus Hand infections
Necrotizing: Mixed Foot infections
Hiradenitis suppurativa: Biliary tract
Staph aureus infections
Lymphangitis: Staph Peritonitis
aureus
Gangrene : synergistic Viral infections
 Hospital-Acquired

SSI (Wound infection)

Pulmonary
Urinary Tract
Intra-abdominal
Empyema
Foreign-body associated
Fungal infection
Multiple organ failure
 Cellulitis and Lymphangitis
- Is non suppurative invasive
infection of tissues with poor
locatization + cardinal signs
of inflammation.

-It is spreading infection

(B-haemolytic streptococci ,
staphylococcus ,
C. perfringens).
-Tissue destruction, gangrene and ulcer may
follow which are caused by release of
proteases and allow spread of infection.
Predisposing factors include:
Lymphoedema
Venous stasis
History of cellulitis
Intravenous drug use
Obesity.
Diabetes mellitus
Surgical wounds
Weakened immune system

Management
Rest and elevation of the affected limb
Antibiotics (orally/ intravenous)
(Benzylpenicillin and flucloxacillin)
Lymphangitis is part of a similar process and presents as painful
red streaks in affected lymphatics.It is associated with painful
lymph node groups in the related drainage area.
Boils are red lumps around a hair follicle that are tender, warm, and
very painful (signs of inflammation).
- pea-sized to golf ball-sized.
- yellow or white point at the center of the lump / discharge pus.
severe fever, swollen lymph nodes, and fatigue.

chronic furunculosis is recurring boil + Systemic factors that

lower resistance : diabetes, obesity, and hematologic
disorders.
 Treatment

Antibiotics against Staphylococcus aureus .

small boil burst and drain
spontaneously

recurrent boils a systemic cause should

be looked for and treated.
 Hidradenitis suppurativa

This is a chronic inflammatory

disease of the apocrine
gland containing skin(axillary
and groin ).

Less common sites :scalp,

breast, chest and perineum.
Hidradenitis suppurativa
+obesity and smoking.
Women are 4x.

The pathophysiology involves follicular occlusion followed by

folliculitis and secondary infection with skin flora (usually
Staphylococcus aureus and Propionibacterium acnes).
Clinically,patients develop tender, subcutaneous
nodules which may not point and discharge,
but usually progress to cause chronic
inflammation , suppurative skin abscesses,
sinus tracts .
 Management

Patients should be
-advised to stop smoking and lose weight
-Symptoms can be reduced by the use of
antiseptic soaps, tea tree oil, non-
compressive and aerated underwear.
-Medical treatments include topical and oral
antibiotics and anti-androgen drugs.
-if abscess developed ,need drainage.
 Abscesses

An abscess is collection of
pus within soft tissues

Pathology
An abscess contains
bacteria, acute In superficial abscesses
inflammatory cells, protein o Staph. Aureus
exudate and necrotic o Strep. pyogenes
tissue,It is surrounded by In deep abscesses
granulation tissue (the o Gram negative species
'pyogenic membrane') (e.g. E. coli)
The pus is composed of dead o Anaerobes (e.g.
and dying white blood cells Bacteroides)
 Clinical features

1- Superficial
abscesses include
infected sebaceous
cysts, breast and
pilonidal abscesses.
superficial abscess shows cardinal features of inflammation - calor,
rubor, dolor, tumor(Heat,Redness,Pain,Swelling)
After few days superficial abscess usually 'point' and are
fluctuant
2-Deep abscesses like; diverticular abscess,
subphrenic abscess and anastomotic
leaks(inside the abdomen)
Patients shows signs of inflammation
o Swinging pyrexia
o Tachycardia
o Tachypnoea
Physical signs are otherwise difficult to
demonstrate
Site of abscess may not be clinically
apparent
 Treatment

(adequate drainage)
Should be performed under general
anaesthesia

Antibiotics have little to offer as

tissue penetration is usually poor

Prolonged antibiotic treatment can

result in a chronic inflammatory
mass (an 'antibioma')

Superficial abscesses open drainage

For deep abscesses closed drainage
Open Technique
Superficial abscesses can usually
be drained through a cruciate incision
Position of incision may allow depended
drainage
Pus should be sent for microbiology
Loculi should be broken down and necrotic
tissue excised
A dressing should be inserted into the wound
Closed Techniques
Deep abscess can be
treated by ultrasound
/CT guided drainage
 What is a
Surgical Site Infection?

SSIs can be defined as an infection that is present

up to 30 days after a surgical procedure if no
implants are placed, and up to one year if an
implantable device was placed in the patient

The majority of SSIs will occur during the first 2-3

weeks after surgery

38% of all nosocomial (hosp. acquired) infections

in surgical patients are SSI
2 to 5% of operated patients will develop a SSI
 Some definitions

Colonization:
presence of bacteria in a wound with no signs or
symptoms of systemic inflammation . usually bacterial
count less than 10*5cfu/ml
Contamination:
Transient exposure of a wound to bacteria.
Varying concentration of bacteria possible.
Time of exposure less than 6 hours.
SSI prophylaxis is best strategy.

Infection:
systemic and local signs of inflammation,
bacterial count more than 10*5cfu/ml
 Types of Surgical Site Infections

According to the tissue involved:

1. Superficial
2. Deep incisional
3. Organ/space
 A superficial incisional SSI must meet one of the
following criteria:

Infection occurs within 30 days after the operative procedure

and
involves only skin and subcutaneous tissue of the incision
and
patient has at least one of the following:
a. purulent drainage from the superficial incision.
b. organisms isolated from an aseptically obtained culture of
fluid or tissue from the superficial incision.
c. at least one of the following signs or symptoms of
infection: pain or tenderness, localized swelling, redness,
or heat, and superficial incision are deliberately opened
by surgeon, and are culture-positive or not cultured. A
culture-negative finding does not meet this criterion.
d. diagnosis of superficial incisional SSI by the surgeon or
attending physician.
 A deep incisional SSI must meet one of
the following criteria:

Infection occurs within 30 days after the operative procedure if no implant

is left in place or within one year if implant is in place and the infection
appears to be related to the operative procedure
and
involves deep soft tissues (e.g., fascial and muscle layers) of the incision
and
patient has at least one of the following:
a. purulent drainage from the deep incision but not from the organ/space
component of the surgical site
b. a deep incision spontaneously dehisces or is deliberately opened by a
surgeon and is culture-positive or not cultured and the patient has at
least one of the following signs or symptoms: fever (>38C), or
localized pain or tenderness. A culture-negative finding does not meet
this criterion.
c. an abscess or other evidence of infection involving the deep incision is
found on direct examination, during reoperation, or by histopathologic
or radiologic examination
d. diagnosis of a deep incisional SSI by a surgeon or attending physician.
 An organ/space SSI must meet one of the
following criteria:

Infection occurs within 30 days after the operative procedure if no

implant is left in place or within one year if implant is in place and the
infection appears to be related to the operative procedure
infection involves any part of the body, excluding the skin incision, fascia,
or muscle layers, that is opened or manipulated during the operative
procedure
and
patient has at least one of the following:
a. purulent drainage from a drain that is placed through a stab wound
into the organ/space
b. organisms isolated from an aseptically obtained culture of fluid or
tissue in the organ/space
c. an abscess or other evidence of infection involving the organ/space
that is found on direct examination, during reoperation, or by
histopathologic or radiologic examination
d. diagnosis of an organ/space SSI by a surgeon or attending physician.
 Further classifications
According to the etiology
Primary SSI :the wound is the primary site for infection
Secondary SSI :infection arise following a complication
that is not directly related to the wound
According to the time
Early with in 30 days
Intermediate 1-3 months
Late more than 3 months
According to Severity
Minor SSI :discharge without cellulites or deep tissue
destruction
Major SSI :pus discharge with tissue breakdown, partial
or total dehiscence or systemic illness
 Source of SSI Pathogens

1. Endogenous flora of the patient

2. Operating theater environment

3. Hospital personnel (doctors/nurses/staff)

4. Seeding of the operative site from distant focus of infection

(prosthetic device, implants)
 Pathogenesis of SSI
Relationship equation

Dose of bacterial contamination x Virulence

Resistance of host

SSI RISK
 Risk factors
1. surgical factors
A. Type of procedure
B. Degree of contamination
C. Duration of operation
D. Urgency of operation
2. patient-specific factors. Patient-specific factors can be further
defined as either
systemic
Advanced age
local Shock
High bacterial load Diabetes
Wound hematoma Malnutrition
Necrotic tissue Alcoholism
Steroids
Foreign body
Chemotherapy
Obesity Immuno-compromise
 Wound Classification
according to the degree of contamination

Wound class Definition Example Infection

rate (%)
Clean Nontraumatic, elective Mastectomy 2%
surgery. GI tract, Vascular
respiratory tract, GU tract Hernias
not entered
Clean- Respiratory, GI, GU tract Gastrectomy < 10%
contaminated entered with minimal Hysterectomy
contamination
Contaminated Open, fresh, traumatic Rupture appy 20%
wounds, uncontrolled Emergent
spillage, minor break in bowel resect.
sterile technique
Dirty Open, traumatic, dirty Intestinal 28-70%
wounds; traumatic fistula
perforation of hollow resection
viscus, frank pus in the
field
 Determinants of the infection
Every surgical site is contaminated by bacteria at the
end of the procedure, few become clinically infected.
Four important determinants lead to either uneventful
wound healing or SSI.

1. Inoculums of the bacteria

2. Virulence of the bacteria
3. Effects of microenvironment
4. Integrity of host defenses (Innate and acquired )
 1. Inoculum of the bacteria

Sources:
Air in operation room
Instruments
Surgeons and staff
Patients flora. Largest inoculum is from
areas that are heavily colonized e.g.
bowel, female GUT, diseased biliary tract
This factor is modifiable
 2. Virulence of the bacteria

The more virulence the bacteria, the greater

probability of infection
Coagulase positive staph
Virulent strain of perfiringens and group A
streptococi
E coli
Bacteroids
This factor can not easily be controlled by
preventive strategies because it is intrinsic to the
procedural site and the type of bacteria that
already colonize the patient
 3. Effects of microenvironment

The following factors in the microenviroment

of the wound predispose to SSI
Necrotic tissue
Hb at the surgical site
FB, drains
Dead space with in the surgical site
Surgical techniques
 4. Integrity of host defenses

Innate host defense deficiency

Acquired host defense deficiency
Shock and hypoxia
Transfusion
Chronic illness
Hypoalbuminaemia
Malnutrition
Hypothermia
Hyperglycemia
Corticosteroids
Obesity
Nicotine use
chemotherapy
 Prevention of SSI

1. Preoperative planning
2. Intra operative technique
3. Preventive antibiotic therapy
4. Enhancement of host defense
5. Post Operative care
 1. Preoperative planning

Control preexisting infection of patient

Postpone the operation if open skin wound or hand infection

of surgeon present

Decrease preoperative hospitalization period

Shower and scrub the surgical site with antiseptic soap the
evening prior to operation

Clipping the hair from surgical site before the operation

 2. Intra operative technique

Skin preparation Avoid dead space

Caps, masks gowns, surgical Insert drains through separate

gloves stab incision

Sterilization of the instruments Leave skin and subcutaneous

tissue open if dirty
Gentle handling of tissue
Sterile dressing
Good haemostasis
Topical ointments
3. Preventive antibiotic therapy

Class 1 = Clean
Class 2 = Clean/contaminated - Prophylatic Antibiotics
Class 3 = Contaminated
Class 4 = Dirty infected Therapautic Antibiotics
 Wound Antibiotic PCN Allergy
Classification
1st generation Vancomycin
I
Cephalosporin Clindamycin
II-Biliary,GU, 1st generation Vancomycin
Upper Digestive Cephalosporin Clindamycin
II-Distal 2nd generation Aztreonam and
Digestive Cephalosporin Clindamycin/Flagyl

III/IV Generally Therapeutic

 Antibiotic Agents

1. Penicillin
blocks the synthesis of the bacterial
wall ---> osmotic instability & lysis
Active against most gram (+) bacteria

2. Cephalosphorin
Bactericidal by inhibiting bacterial cell
wall synthesis
Arranged into generation
For gram (+) and (-) bacteria
3.Erythromycin
Bacteriostatic ; bactericidal in higher
dose

Inhibit bacterial protein synthesis

Treatment of choice in treating

mycoplasm and Legionnaires disease,
also for actinomycosis
4. Tetracyclines
For gram (+) and (-) not sensitive to
penicillin
Good for TB
Bacteriostatic
Interfere w/ protein synthesis
For actinomycosis and nocardiosis
Should be avoided in early childhood
causing yellow discoloration of the
teeth
7. Metronidazole
Bactericidal
Important for obligate anaerobic
bacteria

8. Amphotericin B
Good for antifungal agents
IV, intrathecally or instilled directly to
the site of infection
9. Sulfonamides - Trimethoprim
Effective against community acquired gm
(-)
Orally administered
Has limited usefulnes in nosocomial
infection

10. 4-Fluoroquinolones
Good for nosocomial infections
Good activity against nearly all gram (-)
organism
11. Carbapenems
Has the widest spectrum
Highly effective against most aerobic
(S. aureus & P. aeruginosa) as well as
anaerobic bacteria
4. Enhancement of host defense

1. Increase oxygen delivery

2. Optimizing core body
temperature
3. Blood glucose control
4. Correct any coexisting
condition e.g malnutrition,
anemia
 Postoperative issues
Incision care
The type of postoperative incision care
@ closed primarily: the incision is usually
covered
with a sterile dressing for 24 to 48 hours.
@ left open to be closed later: the incision is
packed
with a sterile dressing.
@ left open to heal by second intention:
packed with
sterile moist gauze and covered with a sterile
dressing.
 Treatment surgical site infection
Efflux of purulent material and pus
Fascia is intact:
debridement
Irrigated with N/S and
packed to its base with saline-moistened gauze
Fascia separated: drainage or reoperation
Most SSIs: healing by secondary intention
 Discharge planning
The intent of discharge planning:
maintain integrity of the healing incision,
educate the patient about the signs and
symptoms
of infection,
advise the patient about whom to contact to
report
any problems.
 References

Bailey and Love Short Pratice of Surgery

Surgical reference Textbook
Medscape
Clinical Surgery
Thank you For listening