Transcript 4- surgical_infectio..

SURGICAL INFECTIONS
Under supervision of :
Dr. MOHAMMED AL-AKEELY
infection
Invasion of the body by pathogenic
microorganisms and reaction of
the host to organisms and their
toxins

A surgical infection is an
infection which requires surgical
treatment and has developed
befor, or as a complication of
surgical treatment.
 could
be life threatening
 Accounts
for 1/3 of surgical
 Increased
cost to healthcare
patients
Some imp defin.
 Bacteremia:
bacteria in blood
 SIRS: systemic inflammatory response
syndrome (fever, tachycardia,
tachypnea, leukocytosis)
 Sepsis: documented infection & SIRAS
 Septic shock: sepsis & hypotension
refractory to fluid resuscitation
Principles of surgical treatment

Debridement- necrotic, injured, dead
tissue
Drainage- abscess, infected fluid
 Removal- infection source, foreign

body

Supportive measures:
• immobilization
• elevation
• antibiotics
Common organisms
Gram positive bacteria:
 Streptococci
 Staphylococci
 Clostridia
Gram negative bacteria:
 Pseudomonas
 E. coli
 Bacteroid fragilis
Streptococcal infections
1.
2.
3.
4.
Cellulitis
Lymphangitis
Lymphadenitis
Necrotizing faciitis
cellulitis

severe inflammation of dermal and subcutaneous layers of
the skin.
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caused by normal skin flora(group A strept /staph)or by
exogenous bacteria.
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the bacteria can spread rapidly, entering the lymph nodes
and the bloodstream and spreading throughout the body.
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In rare cases, the infection can spread to the deep layer of
tissue (Necrotizing faciitis).
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often occurs in broken skin.
cellulitis
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Signs & symptoms: affected area is red, hot, and
tender with vague borders.
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Most common sites : Face, hand and lower extremities.
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RF: old age & immunodeficiency.
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Diagnosis: clinically.
TX:
1- resting, elevation of the affected limb, debridement.
2- ampicillin/amoxicillin in moderate (suspected strept) +
flucloxacillin or dicloxacillin for mild (staph)

cellulitis
Erysipelas
 Erysipelas is the term used for a
more superficial infection of the
dermis and upper subcutaneous
layer that presents clinically with
raised surface and well defined
edge.

Erysipelas and cellulitis often coexist,
so it is often difficult to make a
distinction between the two.
Erysipelas
Lymphangitis
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Lymphangitis is an inflammation of the
lymphatic channels that occurs as a
result of infection at a site distal to the
channel.

Streptococcus pyogenes.

Signs and symptoms: deep reddening
of the skin, warmth, with moderate pain
and swelling. Lymphadenitis, chills and
a high fever along. ( appears as red
streak).
Lymphangitis
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Tx:
1-elevate and immobilize affected areas
to reduce swelling, pain, and the
spread of infection.
2- antibiotic.
Lymphangitis
LYMPHADENITIS
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Lymphadenitis is an infection of the lymph
nodes.
Lymphadenitis may occur after skin infections
or other bacterial infections, particularly those
due to streptococcus or staphylococcus.
Swollen, tender, or hard lymph nodes
Red, tender skin over lymph node
Lymph nodes may feel rubbery if an abscess
has formed.
LYMPHADENITIS
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Treatment may include:
Antibiotics to treat any underlying infection
Analgesics (pain killers) to control pain
Anti-inflammatory medications to reduce
inflammation and swelling
Cool compresses to reduce inflammation
and pain
Surgery may be needed to drain any
abscess.
LYMPHADENITIS
Necrotizing fasciitis
(flesh-eating disease)

Infection and necrosis of the deeper layers of skin and
subcutaneous tissues.

2 types: l:polymicrobial
ll: monomicrobial (mostly group A strept)
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Signs and symptoms: The infection begins locally, at
a site of trauma>>intense pain>> then tissue becomes
swollen (hrs.)
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Common sites: abdominal wall, perineum, and limbs.
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Diagnosis: visual examination & microscopic
evaluation of tissue samples.
Necrotizing fasciitis
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RF: diabetes, abdominal surgery, drug
addict and trauma.
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Tx:
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High mortality rate (75%) if left untreated.
1-Early medical treatment (combination of
intravenous antibiotics including penicillin,
vancomycin, and clindamycin)
2-Cultures are taken to determine appropriate
antibiotic
3-aggressive surgical debridement ( no
definitive boundries!!)
Necrotizing fasciitis
Staphylococcal Infections

Abscess: is a collection of pus (dead

It is a defensive reaction of the tissue to prevent
the spread of infectious materials to other parts
of the body
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neutrophils) that has accumulated in a cavity
formed by the tissue
As Staphylococcus aureus bacteria is a common
cause, an anti-staphylococcus antibiotic such as
flucloxacillin or dicloxacillin is used
Incision and drainage is a common surgical
intervention in case of abscess
Staphylococcal Infections
1.
Furuncle- infection of one hair follicle /
sweat glands
Carbuncle- extension of furuncle into subcut.
Tissue with possible formation of abscess.
“usually more than one furuncle”
common in diabetic patient
common sites- back, back of neck
Treatment: drainage, antibiotics, control
diabetes
2.
Staphylococcal Infections
Clostridial infections
1.
2.
3.
Gas gangrene
Tetanus
Pseudomembranous colitis
GAS GANGRENE
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is a bacterial infection that produces gas in gangrenous
tissues usually caused by Clostridium perfrengins
bacteria.

It is a medical emergency (Progression to toxemia and
shock is often very rapid)

Large wounds contaminated by soil.
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It results in rapid myonecrosis, swelling, seropurulent
discharge, foul smelling wound, crepitus in
subcutaneous tissue.
GAS GANGRENE
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X-ray: gas in muscle and under skin.
Tx:
1-Wound exposure, debridement ,
drainage.
2-Penicillin, clindamycin, metronidazole
3-Hyperbaric oxygen chamber
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GAS GANGRENE
TETANUS
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Cl. Tetani, produce neurotoxin
Penetrating wound ( rusty nail, thorn )
Incubation period: 7-10 days
Usually wound healed when symptoms appear
Trismus- first symptom, stiffness in neck & back
Anxious look with mouth drawn up ( risus sardonicus)
Progressive dysphasia, dysphagia, dyspnea &
tonic convulsion
Death by exhaustion, aspiration or asphyxiation
TETANUS
Treatment:
 wound debridement
 Muscle relaxants, penicillin
 ventilatory support
Prophylaxis:
 vaccination by HTIG & T toxoid in tetanus
prone wound in patient with unknown or
incomplete history of immunization.
 If it is more than 5 years since last dose of
tetanus immunization give only T toxoid.
PSEUDOMEMBRANOUS COLITIS
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Superinfection in patients in long term oral
antibiotic therapy
Cl. Difficile
Watery diarrhea, abdominal pain, fever
Diagnosis needs Sigmoidoscopy, stool- culture
and toxin assay
Treatment :
stop offending antibiotic
oral vancomycin/ metronidazole
rehydration, isolate patient
Pseudomonas

Opportunestic bacteria that may cause surface
infections, but may also cause serious and lethal
infection.
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Enter the body through minor skin abrasion,
ventilator tubes, urinary catheters and IV lines >>>
therefore it is common in ICU.
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Can cause septecimia (particularly in burn
wounds)
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Tx: aminoglycosides, piperacillin, ceftazidine.
E. coli
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Normal intestinal flora, facultative
anearobes.
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May cause circulatory collapse (due to
endotoxin), wound infections, meningitis,
endocarditis, abdominal abscess & UTI.
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Tx: ampicillin, aminoglycosides,
cephalosporine.
Bacteroides fragilis
1.
Normal flora of mouth and colon, anearobic.
Produce foul smelling pus, gas in surrounding
tissues & necrosis.
Responsible for intraabdominal & gyne.
infection.
Causes spiking fever, jaundice & leukocytosis.
Tx:
Surgical drainage, excision.
2.
Clindamycin, metronidazole.
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Hospital aquired infections
The most common is UTI
 The most common causing
death is pneumonia.
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Surgical site infection (SSI)
38% of all surgical infections
 Infection within 30 days of operation
 Classification:
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Superficial: Superficial SSI–infection in subcutaneous plane (47%)
Deep: Subfascial SSI- muscle plane (23%)
Organ/ space SSI- intra-abdominal, other spaces (30%)
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Staph. aureus- most common organism
E coli, Entercoccus ,other Entetobacteriaceae- deep
infections
B fragilis – intrabd. abscess
Surgical site infection (SSI)
Risk factors: age, malnutrition, obesity,
immunocompromised, poor surg. tech,
prolonged surgery, preop. shaving and
type of surgery.
 Diagnosis:
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Sup.SSI- erythema, oedema, discharge and pain
Deep infections- no local signs, fever, pain,
hypotension.
need investigations.
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Treatment: surgical / radiological intervention.
Surgical site infection (SSI)
Intra-abdominal infections
 Generalized
 Localized
 Prevention- good tech., avoid bowel
injury, good anastomosis.
 Diagnosis- History, exam., investigations
CT scan.
 Treatment- surgery/ intervention
Antibiotics (aerobe+ anaerobe)
UTI
UTI are usually consequences of foley
cathetar.
 The most common symptoms of a
bladder infection are burning with
urination (dysuria), frequency of
urination and an urge to urinate.
 may also present with flank pain and
a fever.
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UTI
Diagnostic test:
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-urinalysis (nitrate, estrase)
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-culture
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-urine microscopy (WBC>10)
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The common org. is:
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- E. coli, klebsiella,
enterococcus & staph. aureus
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TREATMENT
Ab.with gram (-) spectrum
-sulphamethoxasole
-trimethoprim
-gentamycin
-ceprofloxacin
 Check culture &sensitivity
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pneumonia
Rout of infection:
-gross aspiration during anesthesia
or intubation. Pathogen includes
anaerobic organism & gram(-)
bacilli.
- Atelectasis: the collapsed lung may
become secondarily infected
-contiguous spread from another site.
pneumonia
Sing & symptoms :
People with pneumonia often have one or more
of these symptoms: Fever, productive cough,
shortness of breath, hypoxia and chest pain.
•
Chest x-ray & sputum culture are important to
confirm the diagnose.
•
treatment
Hospital acquired pneumonia
generally treated by cefuroxime,
ceftriaxone for the usual
pathogen( gram(-), s.aureus ,
strept.pn, & H. influenzae) +
treatment of other pathogen.
 if there is recent Hx of abd.surg
the infectious org. is anaerobes
we should add clindamycin
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If the pt. is comatose or has head
trauma, DM, or renal failure the org.
usually is s.aureus & there is risk of
MRSA
we add vancomycin
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If the pt. take high dose of
glucocorticoides the org. usually is
legionella
we add macrolide
(azithromycin)
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If the pt. has malnutrition, structural lung
disease, glucocorticoid therapy the org.
usually is pseudomonas.a
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Also if the pt. has Hx of neuro.surg. ,head
trauma, ARDS, aspiration the org. usually is
acinetobacter spp.
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All of them treated by the standard treatment
+ aminoglycoside or ciprofloxacin IV +
antipseudomonal penicillin or imipenem.
Sterilization and Disinfection
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Sterilization means ERADICATING all microorganisms and
SPORES.
Disinfection means the eradication of vegetative form only
leaving SPORES.
For sterilization, autoclave is the most common instrument
used.
Antiseptic is used on the surface of the body like alcohol,
chlorohexidine
Disinfectent is applied on metals and other instruments
like formaldehyde = formalin
Plastic materials are best sterilized using chemicals while
metalic instrument can be safely sterilized in the
autoclave.
antibiotics
 Chemotherapeutic
organisms
agents that act on
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Bacteriocidal: Penicillin,Cephalosporin,
Vancomycin, Aminoglycosides
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Bacteriostatic:
Erythromycin,Clindamycin,Tetracycline
COMMON ANTIBIOTICS
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Penicillins- penicillin G
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Cephalosporins (II, III)-Cefruoxime, Ceftriaxone
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Aminoglycosides- Gentamycin
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Fluoroquinolones- Ciprofloxacin
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Glycopeptides- Vancomycin
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Macrolides- Erythromycin,
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Tetracyclines-, Doxycycline
Prophylactic ab.
Prophylaxis
in cleancontaminated or high risk
clean wounds.
 Antibiotic is given just before
patient sent for surgery.
 Duration of antibiotic is
controversial (one dose-or
more , should not be used
more than 24 hour regimen )
Wound Classification
Wound class
Definition
Example
Clean
Nontraumatic, elective
surgery. GI tract,
respiratory tract, GU tract
not entered
Respiratory, GI, GU tract
entered with minimal
contamination
Open, fresh, traumatic
wounds, uncontrolled
spillage, minor break in
sterile technique
Open, traumatic, dirty
wounds; traumatic
perforation of hollow
viscus, frank pus in the
field
Mastectomy
Vascular
Hernias
Cleancontaminated
Contaminated
Dirty
Infection
rate (%)
2%
Gastrectomy
Hysterectomy
< 10%
Rupture appy
Emergent
bowel resect.
20%
Intestinal
fistula
resection
28-70%
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