Surgical infection

Surgical infection
( 2020 )
Surgical Club Red Sea University SC (RSU)

 Prepared by:
 Dr. Shahd 17
 Dr.Alaa 17
 Dr. Samah 18
 Dr. Zaineb 19
 Presented by:
 Dr: Amar Yahia
 Registrar of General Surgery
 Surgical Club Red Sea University SC(RSU) 15/7/2020

*Risk factors of surgical infection :
1-malnutrition.
2-DM.
3-obesity.
4-uremia.
5-jaundice.
6-malignancy.
7-immunosuppression.

8-ischemia.
9-HIV.
10-forignbody.
11-hematoma.

Surgical infection can be :
1- superficial : in the wound .
2- deep : in the deeper facia muscular layer (burst
abdomen – wound dehiscent) .
3- organ space infection … in abdomen (liver abscess) .

1-cellulitis
is a spreading inflammation of subcutaneous and
facial planes follow a small scratch or wound or
incision or insect (snake/scorpion) bite.
*common in the face, upper and Lower limbs and
scroutm.

Clinical features:
- fever , toxicity ( tachycardia , hypotension).
- Diffuse swelling.
- - pain , tenderness, red shiny area of skin.
- - tender regional LN and may be palpable which
indicate severity.
No edge , no pus ,no fluctuation.-

Management:
- - elevation of the limb to reduce oedema .
- - antibiotic : penicillin , cephalosporin's.
- -dressing by glycerine magnesium sulphate.
- bandaging .

Lymphaginitis:
acute non suppurative infection and spreading inflammation of
lymphatic of skin and subcutaneous tissue .
Causes :
- filiariasis (wuchereria bancrofti) is the most common cause.
-B haemolytic streptococci, staph, clostridium following trauma.

Clinical features:
- - Streaky redness ( on pressure area blanches, on
release redness reappear )
- - Oedema , palpable tender LN.
-- Fever and features of toxaemia .
- Regional LN (only) may suppurate
to form abscess.

Management:
-antibiotic: penicillin.
-elevation , rest , glycerine magnesium sulphate .
-management of toxaemia .

3- abscess:
Risk factors:anaemia , age of patient , nutrition , DM , HIV ,
immunosuppression, trauma, RTA.
Type of abscess:
1-pyogenic abscess .
2-pyaemic abscess .
3- metastatic abscess .
4- cold abscess .

Causatives:
Staph Aureus , streptococcus pyogenus , gram (-) bacteria.
Pyogenic abscess:
-localized collection of pus in a cavity, lined by granulation
tissue,coverd by pyogenic membrane.
-pus contain dead WBC, multiplying bacteria, toxin and
necrotic material.

Clinical features:
-fever , throbbing pain and pointing tenderness .
-localized swollen.
-visible (pointing) pus.
-rub or (redness) , dolour (pain), calor (heat),tumor
(swelling).
- Loss of adjacent( tissue / joint) function.
- Fluctuation .

Investigation:
-CBC: increase WBC , decrease Hb .
-RBG .
-CPB , ESR .
-CXR.
-CT , MRI for brain .
-LFT , PO2 , PCO2 .
-blood culture.

Complication:
1- bactermia , Septicaemia , pyemia.
2- multiple abscess formation.
3- metastic abscess.
4- destruction of tissue .
5- antibioma formation . (common in breast abscess).
6- sinus and fistula formation.
7- haemorrhage , as in pancreatic abscess.
8- abscess in head and neck causing laryngeal oedema and stridor.

Complication of internal abscess:
-brain abscess can cause intracranial HTN.
-liver abscess can cause jaundice or hepatic failure .
-lung abscess can cause bronchoplural fistula.

Management:
1-abscess should be aspirated first to get pus.
2-drange by using sinusforceps and breaking of loculi using finger.
3-clean the abscess cavity and irrigated with normal saline and iodine.
4- wound is not closed .
5- send of pus for culture and sensitivity .
6-antibiotic.
7- treat the cause.
DD: soft tissue tumour , hematoma .

Cold abscessPyogenic abscess
-no sign of acute
inflammation.
-tuberculous bacteria .
-non dependent incision.
-wound is sutured .
-no drain .
-Red , warm , tender.
-strepto, staph.
-for drainage (dependent
incision).
-wound is not sutured.
-drain.

Hilton method for abscess drainage:

-Bactermia: presence of bacteria in the blood.
-Septicaemia: presence of over whelming
bacteria in blood and toxin causing SIRS or MODS .
-pyaemia: presence of multiplying bactermia in
the blood as emboli which spread in different organ.

Metastatic abscess:
It is an abscess which spread from other abscess . E.g.
lung abscess causing metastatic abscess in the brain .

Furuncle (boil):
It is acute staphylococcal infection of hair follicle with
perifolliculitis which usually proceed to suppuration and
central necrosis.
TT: antibiotic give if boil not resolving.
Complication: cellulitis , lymphadenitis ,
hidradenitis(infection of group of hair follicle).

Hidradenitis suppurative:
-Chronic infection and fibrous disease of skin in apocrine
sweat glands.
-common in female 4:1.
-most common site is axilla .
TT:
-antibiotic : penicillin.
-excision of involved area .

carbuncle:
-infective gangrene of skin and subcutaneous tissue .
-main cause staph aureus .
-common site nape of neck and the back.
-Common in immunocompromised patient as diabetic.
Investigation:
-blood sugar , urine sugar and Keaton bodies .
-Discharge for C/S. Surgical Club Red Sea University SC (RSU)

TT:
-control of diabetes.
-antibiotic.
-skin graft .
-surgical excision of slough is commonly needed .

Scalded Skin Syndrome
Staphylococcal scalded
skin syndrome (SSSS)
 Bacterial agent is
Staphylococcus aureus
 Toxin mediated disease

Signs & Symptoms
 Skin appears burned (scalded)
 Other symptoms include
malaise, irritability, fever; nose,
mouth and genitalia may be
painful

Exfoliative toxin released at
infection site
Outer layer of skin is lost
Causes body fluid loss and
increase susceptibility to
secondary infection

Prevention and treatment
Only preventative measure is patient isolation
Treatment includes bactericidal antibiotics
Anti-staphylococcals such as penicillinase-
resistant penicillins like cloxacillin
Treatment also includes removal of dead skin

 Signs & Symptoms
 Superficial skin infection
 Blisters just below outer skin
layer
 Blisters replaced by weepy
yellow crust
 There is little fever or pain
 Lymph nodes enlarge near
area
 May result in erysipelas

Epidemiology
most prevalent among children
Most affected are two to six years of age
Disease primarily spread person-to-person
Also spread by insects and fomites

 Prevention and treatment
 Prevention is directed at cleanliness and
avoidance of individuals with impetigo
 Prompt treatment of wounds and application
of antiseptics can lessen chance of infection
 Active cases are treated with penicillin,
erythromycin or vancomycin

Pyogenic granuloma:
-infection lead to formation of un healing granulation
tissue, which protnudes through the wound .
-Site : face , scalp ,finger, toes.
C/P: single , red ,firm nodules , which bleed on touch .
D.D: haemangioma, papilloma.
TT: excision , laser surgery .

Tetanus:
- -infective condition caused by clostridium tetani leading to reflex muscle
spasm .
- -gram (+) anaerobic , non capsulated organism.
Risk factors:
-absence of tetanus toxoid immunization
-improper sterilization in laboratory and operation theatre.
-tattooing and rusted nails.
-RTA.

C/P:
Trismus, lock jaw , stiffness of neck , opisthotonos , sleep less ,
dysphagia, dyspnoea.
Pathogenesis :
By releasing exotoxin (tetanospasmin and tetanolysin).
Sign: trismus, risus sardonicus (smiling faces) , hyperreflexia , tonic
clonic convulsion , fever , tachycardia , urine retention , constipation
(duo to spasm of sphincter).

TT:
-admission and isolation .
-avoid noise and light .
-IV fluid with TPN.
-urinary catheterization.
-nosogastric tube to prevent aspiration .
-Nasal O2 when required.
-anti tetanus globulin (ATG) 3000unit IM.
-antibiotic.
-injection of tetanus toxoid 0.5ml IM.
-prevention of bed sore.

Other supporting measures:
 Remove and destroy the source of the toxin through surgical
exploration and cleaning of the wound (debridement).
 • Bed rest with a nonstimulating environment (dim light,
reduced noise, and stable temperature) may be
recommended.
 • Sedation may be necessary to keep the affected person
calm.
 • Respiratory support with oxygen, endotracheal tube, and
mechanical ventilation may be necessary.Surgical Club Red Sea University SC (RSU)

-diazepam in convolution .
-steroid.
-prevention of DVT.
-good nursing care.
Complication :
Fracture bone, hematoma , aspiration pneumonia
, toxaemia secondary infection .

Gas gangrene:
-infective gangrene caused by clostridium perfringens .
-gram (+) , non motile , capsulated organism.
Clostridium welchii : 60%
Predisposing factor: crush wound , after amputation , RTA , gunshot.
Pathophysiology :
1- spore enter through crush injury .
2- spore germinate.
3- released bacteria will multiply .
4- exotoxin released .

Diabetic woman with rapidly spreading
gangrenous infection
Photo courtesy of T. File MD

Type of exotoxin :
1- lecithinase : haemolytic and membranolytic causing
myositis .
2- haemolysin: cause extensive haemolysis.
3- hyaloronidase : help in rapid spread of gas gangrene .
4- protienese : break down protein of infected tissue .

C/P:
- Incubation period is 1-2days (rapidly spreading infection) .
- 1- wound with foul smelling discharge .
- 2- feature of toxaemia ( fever , tachycardia , pallor ) .
- 3-Crepitus .
4- khaki brown skin due to haemolysis .

Clinical type:
1- fulminate type : rapid progress and cause death .
2- massive type : involve whole of one limb.
3-group type : infection of one group of muscle.
4-single muscle : affecting one single muscle.
5- subcutaneous type: superficial.

Investigation:
-CBC.
-RBG.
-wound culture.
-LFT , urea , creatine .
-PO2 , PCO2.
-bone X-ray.
-x-ray or CT scan for abdomen and chest.

TT:
-hyperbaric oxygen .
-rehydration.
- Fresh blood transfusion (hypotension in gas gangrene is treated with
whole blood transfusion ).
- - injection of benzyl penicillin + metronidazole + aminoglycoside ( if
blood urea is normal ) .
- -debridement .
- -electrolyte management.
- - in sever cases amputation is done as life saving procedure .

Complication:
-septicaemia.
-toxaemia.
-renal failure.
-liver failure .
- -DIC.
- -secondary infection.
- -death.

Mycetoma ( Madura foot )
-chronic granulomatous condition of the foot ,
involving subcutaneous and deep tissue causing
multiple discharging sinuses.
- Type:
- 1-fungal (most common) .
- 2-bacterial.

Pathogenesis :
1- organism enter through prick in foot.
2- reach deeper plane in foot.
3- evoke chronic granulamotus.
4- formation of vesicle.
5- discharging sinuses.

C/f:
1- pain less , diffuse , swollen in the foot.
2- multiple discharging sinuses.
3-limb disability.
-regional LN are not involved unless secondary
bacterial infection is present .
DD: chronic osteomyelitis , TB asteomylitis , cancer.

Investigation:
1- discharge study.
2- gram stain for bacteria.
3- culture in sabouroud agar.
4- x-ray of foot.
TT:
1- anti fungal (amphotecin)
2- long term penicillin.
3- dapsone.
4- in severe case amputation. Surgical Club Red Sea University SC (RSU)

Necrotising fasciitis:
-spreading inflammation of the skin , deep fascia
and soft tissue.
-commonly duo to S.pyogenes.
-trauma is a common precipitating factor .
-muscle is usually not involved in necrotising
dasciitis.

C/F:
1- sudden swelling and pain , ulceration .
2- foul smelled discharge .
3- feature of toxaemia .
4- oliguria.
5- jaundice.
6- feature of SIRS , MODS .

Management:
1- IV fluid , fresh blood transfusion .
2- antibiotic dependon c/s.
3- catheterization and monitoring hourly urine out put.
4- assessment of creatinine , electrolyte.
5-pus culture and blood culture .
6- control of diabetes if patient is diabetic .
7- O2 , ventilator support .
8- radical wound excision of gangrenous tissue.Surgical Club Red Sea University SC (RSU)

Surgical site infection (SSI):
-SSI is the most common complication following
surgical procedure (the first one is post operative
pneumonia ).
Common source of infection :
1- surgical wound , catheter ,drain , sputum ,urine .
2- operation room with out prepare ventilation , nurse ,
surgeons , sterilization of instrument .

Organism causing:
-commonly S.aureus.
-other gram (-) bacteria.

SSI – Wound Classification
Class 1 = Clean
Class 2 = Clean contaminated
Class 3 = Contaminated
Class 4 = Dirty infected
Prophylacti
c antibiotics
indicated
Therapeutic
antibiotics

Types of Surgery
Clean Hernia repair
breast biopsy
1.5%
Clean-
Contaminate
d
Cholecystectomy
Elective bowel
resection
2-5%
Contaminate
d
Emergency bowel
resection
5-30%
Dirty/infected Perforation, abscess 5-30%

Operative Antibiotic Prophylaxis
 Decreases bacterial counts at surgical site
 Given within 60 minutes prior to starting surgery (knife to skin)
 Repeat dose for longer surgery
 Do not continue beyond 24 hours
 Determinants – prevailing pathogens, antibiotic resistance, type of surgery
 Not a substitute for aseptic surgery or good technique

Preop
 Scrub
 Duration? With what?
 Skin preparation
 Iodophors, chlorahexadine, or alcohol
 Hair removal
 Night before? Clipper vs razor
 Antiseptic showering
 Reduce skin flora only

Surgical Site Infection Prevention Bundle
Components
1. Prophylactic antibiotic given within one hour prior
to surgical incision
2. Appropriate prophylactic antibiotic selection for
surgical patients
3.Prophylactic antibiotics discontinued within 24
hours after surgery end time (48 hours for cardiac
surgery)
4.Cardiac surgery patients with controlled 6 A.M.
postoperative serum blood glucose

Surgical Site Infection Prevention
Bundle Components
5. Surgery patients with appropriate hair removal
6. Surgery Patients with Perioperative Temperature
Management – maintaining normothermia
7. Urinary Catheter removal on postoperative Day 1
or 2 with day of surgery being day zero.

Other SSI Prevention Measures
 Protect closed incision with sterile
dressing for 24-48 hours
postoperatively
 Maintain adequate/recommended
ventilation processes in the
operating rooms

Timing of prophylaxis
 Intravenous antibiotics should be given within 60 minutes before skin
incision and as close to time of incision as practically possible
 For caesarian section it can be given pre-incision or after cord
clamping
 Single dose with long-enough half-life to achieve activity for
duration of operation

Management of SSI:
1-management depending the type of SSI.
2- all infected material and pus should be removal
(debridment).
3- suture are removed to allow free drainage .
4- infective fluid is sent for culture .
5- once wound show sign of healing (granulation tissue )
secondary suturing is done.

Surgical infection
Antisepsis: killing of the bacteria in the skin or tissue .
-A sepsis: is prevention of entry of organism.

Sterilization
is the killing or removal of all microorganisms in a
material or on an object.

DISINFECTANTS
 is the reduction of the number of pathogenic
microorganisms to the point where they pose no
danger of disease.
e.g.- Formaldehyde, phenol, ethyl alcohol, soaps.

antimicrobial
is an agent that kills microorganisms or stops their
growth
Can be chemical or physical agents

Patient safety:
Introduction:
- patient safety is the absence of preventable harm to
a patient during the process of health care 8
reduction of risk of unnecessary harm ass with health
care to an acceptable minimum.

-Every point in the process of care giving contains
a certain degree of inherent un safety.

-4 out of 10 are harmed in primary and ambulatory Care settings.
-134 million adverse events occur each year in hospitals,
contributing To 2.6 million deaths annually due to un safe care.
- 42 Ś billion: is the estimated medication errors Cost.

10 patient safety tips for hospitals:
1- prevent central Line - associated blood stream
infections.
2-Re-engineer hospital discharge. (create a simple easy to
understand discharge plan).
3- prevent venous thromboembolism by using evidence
based guide to create VTE protocol.
4-Educate patients about using blood thinners safely.

5-Limit shift duration for hospital staff if possible.
6-consider working with a patient safety organization.
7-use good hospital design principles.
8- Measure the hospital's patient safety culture .
9-build better teams : rapid response Systems.
10-Insert chest tube safely.

Ethics:
-Taking responsibility a basic understanding of ethical &
Medio legal principles is Essential to ensure that the
patients relive the highest possible standard of treatment,
And the clinicians minimize the risk of complaint or
negligence.

*principles of medical ethics:
Core Values of modern medical ethics:
Autonomy: is the right of the individual to act freely ,
following decisions rescilting from his or her own
independent thoughts.
Beneficent: means, doing good, for doctors, this effectively
means that they Act in the best interests of their patients.

Non maleficence: A doctor must not harm his or her patient .
a conflict referred to as (Double effect)) between beneficence &
Non-Maleficence, in That many medical Interventions may cause
damage to the pt This requires pt and doctor Together to weigh up
what is in the pts best interest.
Justice: Respects for the rights and dignity of all human beings.

Confidentiality:
confidentiality. The duties of doctor include to Respect patient's right to
confidentiality .This includes non-Medical information imparted in the
context of the doctor – patient.
- Exceptions to the duty of confidentiality :
1- consent of the patient for their health information to be shared.
2- pablic interest If there is real, immediate and serious risk to the public.
3- Notifiable Diseases e.g.: TB, Malaria, Salmonella

Clinical governance and Risk Management:
Quality Control: should cover every aspect of clinical care
This includes: Access to appropriate treatment options, the right
equipment and building : personal professional
development.(appraisal and revalidation).
-appraisal: feedback on doctor performance.
-Revalidation: Revalidation If specialist continue to be Fit to
practice in their chosen Field.

Risk management:
-critical incident forms .
-staff concerns.
- morbidity & Mortality Meeting
-Audit o to identify areas and extent of weak performance.
-compression measures between individuals :organizations
to produce guidelines to minimize risk.

incident Reporting:
Regular reporting of all incidents including near
miss incidents, results in improvement safety.
patient safety incident: is any un
intended or unexpected incident that Could have
led or did Lead to harm for one or more patients.

concenter un toward Incidents:
E.g. : unexpected or avoidable death of one or
more patients, staff , Victors or members of public.
- serious harm to one or more patients staff visitors
that require life saving intervention .

Never events : Are very serious, largely preventable patient
safety,
Incidents that should not occur if the relevant preventable
measures Hare been put in place.
The list of Never events for 2011/2012 :
1-wrong site surgery.
2-wrong implant.
3- Retained foreign object after surgery intervention.

4- Wrongly prepared high-risk injectable medication.
5- Maladministration of potassium containing Solutions.
6- wrong route of administration of chemotherapy.
7-I.V. administration of epidural medication
8- Maladministration of insulin.

9 -overdose of midazolam during conscious sedation.
10- Opioid overdose in opioid - naive patient.
11- Trans fusion of ABO incompatible blood.
12-Transplantation of ABO or HLA incompatible organs.
13- Misplaced naso-or orogastric tubes.
14- wrong gas administered .
15-severe scalding of patients.

Surgical outcomes, Audit Cycle 8 clinical decision making:
-Surgical outcome: is defined as the end result of either specific
Intervention or the pts management as a whole.
-out come may be assessed:
1-subjectively: patient satisfaction questioner.
2- objectively: survivorship data, time to discharge.
-outcome categorized in term of :
1-physical health.
2-mental health.
3-social health.

Patient satisfaction : is Multi factorial, drawing a combination of
physical, mental , social health.
The audit cycle :
The collective review, evaluation & improvement of practice with the
common aim of improving patient care and out comes .
Functions:
1-Encourage improvement in clinical procedure.
2- raise over all quality of clinical care.
3-Educate all members of the team

CLINICAL DISCISION MAKING
 * THE BASICS OF DICISION MAKING:
 1.Personal knowledge : background knowledge & foreground knowledge
 2. Senior review: decision-making guided by someone of greater experience
 3. Guidelines and protocols.
 *STAGES OF DECISION-MAKING:
1. Assessment & diagnosis
2. Planning (strategy)
3. Intervention
4. evaluation

CONT…
 *WORKING IN TEAMS:
• Sharing information within the wider team is
important for safe &effective patient care.
• “ Delegation ”:asking colleague to provide
treatment on your behalf
• “ retinal “: transferring responsibilities for the patient
care to outside your competence.

MEDICAL NEGLIGENCE
 Definition: negligence is a civil wrong that occurs when one part
breach their duty of care owed to another, causing the latter to
sustain an injury or a loss.
 Elements of negligence:
• Duty of care: all doctors have a duty to provide patients with care to
an acceptable standards.
• Breach of duty: once the duty of care has established ,a claimant
must then demonstrate that the doctor failed to meet the duty.

CONT..elements of negligence
• Incompetence: if a breach of duty of care has not caused
harm to a patient it may still that the GMC will choose to
instigate incompetence proceeding against the doctor.
• Gross negligence: this occurs when a disregard of the duty of
care is shown as to amount to recklessness. Should this lead to
a patient death? Then this may constitute criminal
negligence.

INFORMED COSENT
 Definition of consent:
• Capacity: for the consent to be valid the patient must be able
to:
▪ Understand the information given to them.
▪ Retain this information.
▪ Process information to form decision.
▪ Communicate this decision.

Information required
 The information provided to the patient must include:
1. The nature of the disease and its natural history if not
treated.
2. A basic understanding of the nature of the procedure.
3. Serious or frequency occurring risks.
4. Alternative treatment options.

 #Verbal & implied consent:
• Verbal consent: refers to patient stating their agreement to a medical
intervention.
• Implied consent: normally refers to the inference, from the patient’s
conduct , that they agree to the procedure proposed to them.
 #person that can obtain consent:
• it’s the operating surgeon responsibility , the person taking consent must
be sufficiently trained to have appropriate knowledge of the procedure
, alternatives and inherent risks.

# person that can give consent:
• The general role is that only patients themselves can give
consent.
• For their consent to be valid they should have mental
capacity to:
✓ Understand the information.
✓ Retain it.
✓ Process it meaningfully.
✓ Communicating it.

# lack of capacity: either temporary:”e.g :
unconscious patient” or permanent.
*children: only PARENTS or those with legal parental
responsibility can legally give consent on behalf of
their children.
From age 16 onwards minors are deemed to have
capacity to provide their own consent on their own
behalf.

*physical restrictions:
• some patients e.g. those with hand injuries may be
physically unable to sign a consent form, this should not
be confused with a lack of mental capacity.
• Most trust consent form have an area there a witness
can sign on a patients behalf if they are unable to sign,
this should be used, not mental incapacity form.

COST OF SURGERY
 #divided into:
Direct medical cost [e.g; personnel m drugs]
Indirect medical cost [buildings]
Indirect cost of loss productivity [e.g day-off work]
Intangible costs [pain]

consequences of surgery:
+ve: { relive of symptoms; increasing life
expectancy }
-ve: {complications; period of hospitalization }

References
 SRB's Manual of Surgery, 5th. Edition
 Bailey & Love's Short Practice of Surgery, 27th edition
 MRCS Part A_ Essential Revision Notes_ Book 1.

Surgical infection

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