SURGICAL INFECTIONSSURGICAL INFECTIONS

Under supervision of : Under supervision of :

Dr. MOHAMMED AL-AKEELYDr. MOHAMMED AL-AKEELY

infectioninfection

Invasion of the body by pathogenic Invasion of the body by pathogenic microorganisms microorganisms and reaction of and reaction of the host to organisms and their the host to organisms and their toxinstoxins

A surgical infection is an A surgical infection is an infection which requires surgical infection which requires surgical treatment and has developed treatment and has developed befor, or as a complication of befor, or as a complication of surgical treatment.surgical treatment.

could be life threatening could be life threatening

Accounts for 1/3 of surgical Accounts for 1/3 of surgical patientspatients

Increased cost to healthcare Increased cost to healthcare

Some imp definSome imp defin..

Bacteremia: bacteria in bloodBacteremia: bacteria in blood SIRS: systemic inflammatory response SIRS: systemic inflammatory response

syndrome (fever, tachycardia, syndrome (fever, tachycardia, tachypnea, leukocytosis)tachypnea, leukocytosis)

Sepsis: documented infection & SIRASSepsis: documented infection & SIRAS Septic shock: sepsis & hypotension Septic shock: sepsis & hypotension

refractory to fluid resuscitationrefractory to fluid resuscitation

Debridement-Debridement- necrotic, injured, dead necrotic, injured, dead tissuetissue

Drainage-Drainage- abscess, infected fluidabscess, infected fluid Removal-Removal- infection source, foreign infection source, foreign

bodybody Supportive measures:Supportive measures:

• immobilizationimmobilization• elevationelevation• antibioticsantibiotics

Principles of surgical Principles of surgical treatment treatment

Common organisms Common organisms

Gram positive bacteria:Gram positive bacteria: StreptococciStreptococci StaphylococciStaphylococci ClostridiaClostridiaGram negative bacteria:Gram negative bacteria: PseudomonasPseudomonas E. coliE. coli Bacteroid fragilisBacteroid fragilis

Streptococcal infectionsStreptococcal infections

1.1. CellulitisCellulitis

2.2. LymphangitisLymphangitis

3.3. LymphadenitisLymphadenitis

4.4. Necrotizing faciitisNecrotizing faciitis

cellulitiscellulitis

severe inflammation of dermal and subcutaneous layers of severe inflammation of dermal and subcutaneous layers of

the skin.the skin.

caused by normal skin flora(group A strept /staph)or by caused by normal skin flora(group A strept /staph)or by

exogenous bacteria.exogenous bacteria.

the bacteria can spread rapidly, entering the lymph nodes the bacteria can spread rapidly, entering the lymph nodes

and the bloodstream and spreading throughout the body.and the bloodstream and spreading throughout the body.

In rare cases, the infection can spread to the deep layer of In rare cases, the infection can spread to the deep layer of

tissue (tissue (Necrotizing faciitisNecrotizing faciitis).).

often occurs in broken skinoften occurs in broken skin..

cellulitiscellulitis

Signs & symptoms: Signs & symptoms: affected area is red, hot, and affected area is red, hot, and

tender with vague borders.tender with vague borders.

Most common sites Most common sites :: Face, hand and Face, hand and lower extremitieslower extremities..

RF:RF: old age & immunodeficiency. old age & immunodeficiency.

Diagnosis:Diagnosis: clinicallyclinically..

TX:TX:1- 1- resting, elevation of the affected limb, debridement.resting, elevation of the affected limb, debridement.2- ampicillin/amoxicillin in moderate (suspected strept) + 2- ampicillin/amoxicillin in moderate (suspected strept) +

flucloxacillin or dicloxacillin for mild (staph)flucloxacillin or dicloxacillin for mild (staph)

cellulitiscellulitis

ErysipelasErysipelas

ErysipelasErysipelas is the term used for a is the term used for a more superficial infection of the more superficial infection of the dermis and upper subcutaneous dermis and upper subcutaneous layer that presents clinically with layer that presents clinically with raised surface and well defined raised surface and well defined edge.edge.

Erysipelas and cellulitis often Erysipelas and cellulitis often coexist, so it is often difficult to coexist, so it is often difficult to make a distinction between the make a distinction between the two.two.

ErysipelasErysipelas

Lymphangitis Lymphangitis

Lymphangitis is an inflammation of Lymphangitis is an inflammation of the lymphatic channels that occurs as the lymphatic channels that occurs as a result of infection at a site distal to a result of infection at a site distal to the channel.the channel.

Streptococcus pyogenes. Streptococcus pyogenes.

Signs and symptoms: Signs and symptoms: deep deep reddening of the skin, warmth, with reddening of the skin, warmth, with moderate pain and swelling. moderate pain and swelling. Lymphadenitis, chills and a high fever Lymphadenitis, chills and a high fever along. ( appears as red streak).along. ( appears as red streak).

LymphangitisLymphangitis

Tx: Tx: 1-elevate and immobilize affected areas 1-elevate and immobilize affected areas

to reduce swelling, pain, and the to reduce swelling, pain, and the spread of infection.spread of infection.

2- antibiotic.2- antibiotic.

LymphangitisLymphangitis

LYMPHADENITISLYMPHADENITIS

Lymphadenitis is an infection of the Lymphadenitis is an infection of the lymph nodes.lymph nodes.

Lymphadenitis may occur after skin Lymphadenitis may occur after skin infections or other bacterial infections, infections or other bacterial infections, particularly those due to streptococcus particularly those due to streptococcus or staphylococcus.or staphylococcus.

Swollen, tender, or hard lymph nodesSwollen, tender, or hard lymph nodes Red, tender skin over lymph nodeRed, tender skin over lymph node Lymph nodes may feel rubbery if an Lymph nodes may feel rubbery if an

abscess has formed.abscess has formed.

LYMPHADENITISLYMPHADENITIS

Treatment may include:Treatment may include: Antibiotics to treat any underlying Antibiotics to treat any underlying

infectioninfection Analgesics (pain killers) to control painAnalgesics (pain killers) to control pain Anti-inflammatory medications to reduce Anti-inflammatory medications to reduce

inflammation and swellinginflammation and swelling Cool compresses to reduce inflammation Cool compresses to reduce inflammation

and painand pain Surgery may be needed to drain any Surgery may be needed to drain any

abscess.abscess.

LYMPHADENITISLYMPHADENITIS

Necrotizing fasciitis Necrotizing fasciitis (flesh-eating disease)(flesh-eating disease)

Infection and necrosis of the deeper layers of skin Infection and necrosis of the deeper layers of skin and subcutaneous tissues.and subcutaneous tissues.

2 types2 types: : l:polymicrobiall:polymicrobial ll: monomicrobialll: monomicrobial (mostly group A strept)(mostly group A strept)

Signs and symptoms: Signs and symptoms: The infection begins locally, The infection begins locally, at a site of trauma>>intense pain>> then tissue at a site of trauma>>intense pain>> then tissue becomes swollen (hrs.)becomes swollen (hrs.)

Common sitesCommon sites: : abdominal wall, perineum, and abdominal wall, perineum, and limbs.limbs.

Diagnosis:Diagnosis: visual examination & microscopic visual examination & microscopic evaluation of tissue samplesevaluation of tissue samples..

Necrotizing fasciitisNecrotizing fasciitis

RF:RF: diabetes, abdominal surgery, drug diabetes, abdominal surgery, drug addict and traumaaddict and trauma..

Tx:Tx: 1-Early medical treatment (combination of 1-Early medical treatment (combination of

intravenous antibiotics including penicillin, intravenous antibiotics including penicillin, vancomycin, and clindamycin)vancomycin, and clindamycin)

2-Cultures are taken to determine 2-Cultures are taken to determine appropriate antibiotic appropriate antibiotic

3-aggressive surgical debridement ( no 3-aggressive surgical debridement ( no definitive boundries!!)definitive boundries!!)

High mortality rateHigh mortality rate (75%) if left (75%) if left untreated.untreated.

Necrotizing fasciitisNecrotizing fasciitis

Abscess: Abscess: is a collection of pus (dead is a collection of pus (dead neutrophils) that has accumulated in a cavity neutrophils) that has accumulated in a cavity formed by the tissue formed by the tissue

It is a defensive reaction of the tissue to It is a defensive reaction of the tissue to prevent the spread of infectious materials to prevent the spread of infectious materials to other parts of the bodyother parts of the body

As As Staphylococcus aureusStaphylococcus aureus bacteria is a bacteria is a common cause, an anti-staphylococcus common cause, an anti-staphylococcus antibiotic such as flucloxacillin or dicloxacillin antibiotic such as flucloxacillin or dicloxacillin is usedis used

Incision and drainage is a common Incision and drainage is a common surgical intervention in case of abscess surgical intervention in case of abscess

Staphylococcal Staphylococcal InfectionsInfections

Staphylococcal Staphylococcal InfectionsInfections

1.1. Furuncle-Furuncle- infection of one hair follicle / infection of one hair follicle / sweat glandssweat glands

2.2. Carbuncle-Carbuncle- extension of furuncle into extension of furuncle into subcut. Tissue with possible formation of subcut. Tissue with possible formation of abscess. abscess.

“ “usually more than one furuncle”usually more than one furuncle” common in diabetic patient common in diabetic patient common sites- back, back of neckcommon sites- back, back of neck Treatment: drainage, antibiotics, control Treatment: drainage, antibiotics, control

diabetesdiabetes

Staphylococcal Staphylococcal InfectionsInfections

Clostridial infectionsClostridial infections

1.1. Gas gangreneGas gangrene

2.2. TetanusTetanus

3.3. Pseudomembranous colitisPseudomembranous colitis

GAS GANGRENEGAS GANGRENE

is a bacterial infection that produces gas in is a bacterial infection that produces gas in gangrenous tissues usually caused by Clostridium gangrenous tissues usually caused by Clostridium perfrengins bacteria.perfrengins bacteria.

It is a medical emergencyIt is a medical emergency (Progression to toxemia (Progression to toxemia and shock is often very rapid)and shock is often very rapid)

Large wounds contaminated by soil.Large wounds contaminated by soil.

It results in rapid myonecrosis, swelling, seropurulent It results in rapid myonecrosis, swelling, seropurulent discharge, foul smelling wound, crepitus in discharge, foul smelling wound, crepitus in subcutaneous tissue.subcutaneous tissue.

GAS GANGRENEGAS GANGRENE

X-ray: X-ray: gas in muscle and under skin.gas in muscle and under skin.

Tx: Tx:

1-Wound exposure, debridement , 1-Wound exposure, debridement , drainage.drainage.

2-Penicillin, clindamycin, metronidazole2-Penicillin, clindamycin, metronidazole

3-Hyperbaric oxygen chamber3-Hyperbaric oxygen chamber

GAS GANGRENEGAS GANGRENE

TETANUSTETANUS

Cl. Tetani, produce neurotoxinCl. Tetani, produce neurotoxinPenetrating wound Penetrating wound ( rusty nail, thorn )( rusty nail, thorn )

Incubation period: 7-10 daysIncubation period: 7-10 daysUsually wound healed when symptoms appearUsually wound healed when symptoms appearTrismus- first symptom, stiffness in neck & backTrismus- first symptom, stiffness in neck & backAnxious look with mouth drawn up Anxious look with mouth drawn up ( risus ( risus

sardonicus)sardonicus)

Progressive dysphasia, dysphagia, dyspnea & Progressive dysphasia, dysphagia, dyspnea & tonic convulsion tonic convulsion

Death by exhaustion, aspiration or asphyxiationDeath by exhaustion, aspiration or asphyxiation

TETANUSTETANUS

Treatment:Treatment: wound debridementwound debridement Muscle relaxants, penicillinMuscle relaxants, penicillin ventilatory supportventilatory support

Prophylaxis:Prophylaxis: vaccination by HTIG & T toxoid in tetanus vaccination by HTIG & T toxoid in tetanus

prone wound in patient with unknown or prone wound in patient with unknown or incomplete history of immunization.incomplete history of immunization.

If it is more than 5 years since last dose of If it is more than 5 years since last dose of tetanus immunization give only T toxoid. tetanus immunization give only T toxoid.

Superinfection in patients in long term oral Superinfection in patients in long term oral antibiotic therapyantibiotic therapy

Cl. DifficileCl. Difficile Watery diarrhea, abdominal pain, feverWatery diarrhea, abdominal pain, fever Diagnosis needs Sigmoidoscopy, stool- culture Diagnosis needs Sigmoidoscopy, stool- culture

and toxin assayand toxin assay

Treatment :Treatment : stop offending antibioticstop offending antibiotic oral vancomycin/ metronidazoleoral vancomycin/ metronidazole rehydration, isolate patient rehydration, isolate patient

PSEUDOMEMBRANOUSPSEUDOMEMBRANOUS COLITISCOLITIS

PseudomonasPseudomonas

Opportunestic bacteria that may cause surface Opportunestic bacteria that may cause surface infections, but may also cause serious and infections, but may also cause serious and lethal infection.lethal infection.

Enter the body through minor skin abrasion, Enter the body through minor skin abrasion, ventilator tubes, urinary catheters and IV lines ventilator tubes, urinary catheters and IV lines >>> therefore it is>>> therefore it is common in ICU.common in ICU.

Can cause Can cause septecimiaseptecimia (particularly in burn (particularly in burn wounds)wounds)

Tx: Tx: aminoglycosides, piperacillin, ceftazidineaminoglycosides, piperacillin, ceftazidine..

E. coliE. coli

Normal intestinal flora, facultative Normal intestinal flora, facultative anearobes.anearobes.

May cause May cause circulatory collapsecirculatory collapse (due to (due to endotoxin), wound infections, meningitis, endotoxin), wound infections, meningitis, endocarditis, abdominal abscess & UTI.endocarditis, abdominal abscess & UTI.

Tx: Tx: ampicillin, aminoglycosides, ampicillin, aminoglycosides, cephalosporine.cephalosporine.

Bacteroides fragilisBacteroides fragilis

Normal flora of mouth and colon, anearobic.Normal flora of mouth and colon, anearobic. Produce foul smelling pus, gas in surrounding Produce foul smelling pus, gas in surrounding

tissues & necrosis.tissues & necrosis. Responsible for intraabdominal & gyne. Responsible for intraabdominal & gyne.

infection.infection. Causes spiking fever, jaundice & leukocytosis.Causes spiking fever, jaundice & leukocytosis. Tx: Tx:

1.1. Surgical drainage, excision.Surgical drainage, excision.

2.2. Clindamycin, metronidazoleClindamycin, metronidazole..

Hospital aquired Hospital aquired infectionsinfections

The most common is UTIThe most common is UTI The most common causing The most common causing

death is pneumonia.death is pneumonia.

38% of all surgical infections38% of all surgical infections Infection within 30 days of operationInfection within 30 days of operation Classification:Classification: Superficial: Superficial: Superficial SSI–infection in subcutaneous plane Superficial SSI–infection in subcutaneous plane

(47%)(47%)

Deep:Deep: Subfascial SSI-Subfascial SSI- muscle plane (23%)muscle plane (23%)

Organ/ space SSI-Organ/ space SSI- intra-abdominal, other spaces (30%)intra-abdominal, other spaces (30%)

Staph. aureus-Staph. aureus- most common organism most common organism E coliE coli, Entercoccus ,other Entetobacteriaceae- deep , Entercoccus ,other Entetobacteriaceae- deep

infectionsinfections B fragilis – intrabd. abscessB fragilis – intrabd. abscess

Surgical site infection Surgical site infection (SSI)(SSI)

Risk factors: Risk factors: age, malnutrition, age, malnutrition, obesity, immunocompromised, poor obesity, immunocompromised, poor surg. tech, prolonged surgery, preop. surg. tech, prolonged surgery, preop. shaving and type of surgery.shaving and type of surgery.

Diagnosis:Diagnosis: Sup.SSI- erythema, oedema, discharge and pain Sup.SSI- erythema, oedema, discharge and pain Deep infections- no local signs, fever, pain, Deep infections- no local signs, fever, pain,

hypotension. hypotension. need investigations. need investigations. TreatmentTreatment:: surgical / radiological interventionsurgical / radiological intervention. .

Surgical site infection Surgical site infection (SSI)(SSI)

Intra-abdominal infectionsIntra-abdominal infections GeneralizedGeneralized LocalizedLocalized Prevention- good tech., avoid bowel Prevention- good tech., avoid bowel

injury, good anastomosis.injury, good anastomosis. Diagnosis- History, exam., Diagnosis- History, exam.,

investigations CT scan.investigations CT scan. Treatment- surgery/ interventionTreatment- surgery/ intervention Antibiotics Antibiotics (aerobe+ anaerobe)(aerobe+ anaerobe)

Surgical site infection Surgical site infection (SSI)(SSI)

UTIUTI

UTI are usually consequences of UTI are usually consequences of foley cathetar. foley cathetar.

The most common symptoms of a The most common symptoms of a bladder infection are burning with bladder infection are burning with urination (urination (dysuria), frequency of ), frequency of urination and an urge to urinate.urination and an urge to urinate.

may also present with may also present with flank pain and a and a fever..

UTIUTI

Diagnostic test:Diagnostic test: -urinalysis (nitrate, estrase)-urinalysis (nitrate, estrase) -culture-culture -urine microscopy (WBC>10)-urine microscopy (WBC>10)

The common org. is:The common org. is: - - E. coliE. coli, klebsiella, , klebsiella,

enterococcus & staph. aureusenterococcus & staph. aureus

TREATMENTTREATMENT

Ab.with gram (-) spectrumAb.with gram (-) spectrum

-sulphamethoxasole-sulphamethoxasole

-trimethoprim-trimethoprim

-gentamycin-gentamycin

-ceprofloxacin-ceprofloxacin Check culture &sensitivityCheck culture &sensitivity

pneumoniapneumonia

Rout of infectionRout of infection:: -gross aspiration during anesthesia-gross aspiration during anesthesia or intubation. Pathogen includesor intubation. Pathogen includes anaerobic organism & gram(-) anaerobic organism & gram(-) bacilli.bacilli.

-- Atelectasis: the collapsed lung may Atelectasis: the collapsed lung may

become secondarily infectedbecome secondarily infected

-contiguous spread from another site.-contiguous spread from another site.

pneumoniapneumonia

Sing & symptoms :Sing & symptoms :• People with pneumonia often have one or more of these symptoms: Fever, productive cough, Fever, productive cough, shortness of breath, hypoxia and chest pain.shortness of breath, hypoxia and chest pain.

• Chest x-ray & sputum culture are important to Chest x-ray & sputum culture are important to confirm the diagnose. confirm the diagnose.

treatmenttreatment

Hospital acquired pneumonia Hospital acquired pneumonia generally treated by generally treated by cefuroxime, cefuroxime, ceftriaxoneceftriaxone for the usual for the usual pathogen( gram(-), s.aureus , pathogen( gram(-), s.aureus , strept.pn, & H. influenzae) + strept.pn, & H. influenzae) + treatment of other pathogen.treatment of other pathogen.

if there is recent Hx of abd.surg if there is recent Hx of abd.surg the infectious org. is anaerobes the infectious org. is anaerobes we should add we should add clindamycin clindamycin

If the pt. is comatose or has head If the pt. is comatose or has head trauma, DM, or renal failure the trauma, DM, or renal failure the org. usually is s.aureus & there is org. usually is s.aureus & there is risk of MRSA we add risk of MRSA we add vancomycinvancomycin

If the pt. take high dose of If the pt. take high dose of glucocorticoides the org. usually is glucocorticoides the org. usually is legionella we add legionella we add macrolide macrolide (azithromycin)(azithromycin)

If the pt. has malnutrition, structural lung If the pt. has malnutrition, structural lung disease, glucocorticoid therapy the org. disease, glucocorticoid therapy the org. usually is pseudomonas.ausually is pseudomonas.a

Also if the pt. has Hx of neuro.surg. ,head Also if the pt. has Hx of neuro.surg. ,head trauma, ARDS, aspiration the org. usually is trauma, ARDS, aspiration the org. usually is acinetobacter spp. acinetobacter spp.

All of them treated by the standard All of them treated by the standard treatment + treatment + aminoglycoside or ciprofloxacin aminoglycoside or ciprofloxacin IVIV + + antipseudomonal penicillin or antipseudomonal penicillin or imipenem. imipenem.

Sterilization and Sterilization and DisinfectionDisinfection

Sterilization means ERADICATING all microorganisms Sterilization means ERADICATING all microorganisms and SPORES.and SPORES.

Disinfection means the eradication of vegetative form Disinfection means the eradication of vegetative form only leaving SPORES.only leaving SPORES.

For sterilization, autoclave is the most common For sterilization, autoclave is the most common instrument used.instrument used.

Antiseptic is used on the surface of the body like Antiseptic is used on the surface of the body like alcohol, chlorohexidinealcohol, chlorohexidine

Disinfectent is applied on metals and other instruments Disinfectent is applied on metals and other instruments like formaldehyde = formalinlike formaldehyde = formalin

Plastic materials are best sterilized using chemicals Plastic materials are best sterilized using chemicals while metalic instrument can be safely sterilized in the while metalic instrument can be safely sterilized in the autoclave.autoclave.

antibioticsantibiotics

Chemotherapeutic agents that act on Chemotherapeutic agents that act on organismsorganisms

Bacteriocidal:Bacteriocidal: Penicillin,Cephalosporin, Penicillin,Cephalosporin, Vancomycin, AminoglycosidesVancomycin, Aminoglycosides

Bacteriostatic:Bacteriostatic: Erythromycin,Clindamycin,TetracyclineErythromycin,Clindamycin,Tetracycline

COMMON ANTIBIOTICSCOMMON ANTIBIOTICS

PenicillinsPenicillins- - penicillin Gpenicillin G

Cephalosporins (II, III)Cephalosporins (II, III)--Cefruoxime, CeftriaxoneCefruoxime, Ceftriaxone

AminoglycosidesAminoglycosides- - GentamycinGentamycin

FluoroquinolonesFluoroquinolones- - CiprofloxacinCiprofloxacin

GlycopeptidesGlycopeptides- - VancomycinVancomycin

MacrolidesMacrolides- - Erythromycin, Erythromycin,

TetracyclinesTetracyclines--, Doxycycline, Doxycycline

Prophylactic ab.Prophylactic ab.

Prophylaxis in clean-Prophylaxis in clean-contaminated or high risk contaminated or high risk clean wounds.clean wounds.

Antibiotic is given just before Antibiotic is given just before patient sent for surgery.patient sent for surgery.

Duration of antibiotic is Duration of antibiotic is controversial (one dose-or controversial (one dose-or more , should not be used more , should not be used more than 24 hour regimen )more than 24 hour regimen )

Wound ClassificationWound Classification

Wound class Definition Example Infection rate (%)

Clean Nontraumatic, elective surgery. GI tract, respiratory tract, GU tract not entered

Mastectomy Vascular Hernias

2%

Clean-contaminated

Respiratory, GI, GU tract entered with minimal contamination

Gastrectomy Hysterectomy

< 10%

Contaminated Open, fresh, traumatic wounds, uncontrolled spillage, minor break in sterile technique

Rupture appy Emergent bowel resect.

20%

Dirty Open, traumatic, dirty wounds; traumatic perforation of hollow viscus, frank pus in the field

Intestinal fistula resection

28-70%

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