Surgical wound infection Dr Hatem El Gohary


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Surgical wound infection Dr Hatem El Gohary

  1. 1. Dr. Hatem ElGohary Lecturer of General Surgery MD, MRCS
  2. 2. PHYSIOLOGY  Micro-organisms are normally prevented from causing infection in tissues by intact epithelial surfaces. These are broken down in trauma and by surgery.  Protective mechanisms against infection can be divided into: • Chemical: low gastric pH; • Humoral: antibodies, complement and opsonins; • Cellular: phagocytic cells, macrophages, killer lymphocytes.
  3. 3. Risk factors for increased risk of wound infection ■ Malnutrition (obesity, weight loss) ■ Metabolic disease (diabetes, uraemia, jaundice) ■ Immunosuppression (cancer, AIDS, steroids, chemotherapy and radiotherapy) ■ Colonisation and translocation in the gastrointestinal tract ■ Poor perfusion (systemic shock or local ischaemia) ■ Foreign body material ■ Poor surgical technique (dead space, haematoma)
  5. 5. Symptoms Fever Throbbing pain Pus or watery discharge
  6. 6. Signs Redness excessive swelling in the wound tenderness in the wound area
  7. 7. Wound Classification  Class I (Clean) Operative wound clean, no inflammation, Respiratory, gastrointestinal and genitor- urinary tracts not entered. Examples: Thyroidectomy, mastectomy. Infection rate: 1-2%
  8. 8.  Class II (Clean Contaminated) Operative wound clean-contaminated Gastrointestinal, respiratory or genitor-urinary tracts entered without significant spillage Examples: Appendectomy, cholecystectomy. Infection rate: 20-30 %
  9. 9.  Class III (Contaminated) Operative wound contaminated Gross spillage from the gastrointestinal tract, genito-urinary or biliary tracts. Example: Colectomy. Infection rate: up to 60%
  10. 10.  Class IV (Dirty Infected) Operative wound dirty Traumatic wound from dirty source, Fecal contamination, Foreign body. Examples: Drainage of Abscess Debridement of Diabetic foot. Infection rate: more than 60%.
  11. 11. Types of localized infection Abscess (Acute suppurative inflammation +Localized Collection of pus).  Caused by Staphylococcus aureus  Pus (dead and dying white blood cells).  Surrounded by Pyogenic membrane.  C/P: Redness, Hotness, Tenderness and edema.  Treatment: Incision and drainage.
  12. 12. Cellulitis and Lymphangitis (non suppurative diffuse inflammation).  Caused by β-haemolytic streptococci.  C/P: Redness, Hotness, Tenderness and edema.  Treatment: Antibiotics.
  13. 13. Specific wound infections Gas gangrene  Caused by C. perfringens. Gram-positive, anaerobic bacilli found in soil and faeces.  Common in wounds containing necrotic or foreign material.  C/P: severe local wound pain and crepitus (gas in the tissues).  X-ray: Gas in tissues.  Treatment: 1.Intravenous penicillin. 2.Aggressive debridement of affected tissues.
  14. 14. Tetanus  Caused by Clostridium tetani (anaerobic, Gram- positive bacterium).  common in traumatic civilian or military wounds.  Mechanism: release of the exotoxin tetanospasmin, which affects myo-neural junctions and the motor neurones of the anterior horn of the spinal cord.  C/P: prodromal period, leads to spasms in the distribution of the motor nerves of the face followed by the development of severe generalised motor spasms respiratory arrest and death.
  15. 15.  Treatment: 1. Prophylaxis with tetanus toxoid is the best preventative treatment 2. Debridement of the wound may need to be performed. 3. Antibiotic treatment with benzylpenicillin 4. Ventilation in respiratory spasm.
  17. 17. Prophylaxis 1.Prophylactic antibiotics  Maximal blood and tissue levels should be present at the time incision is made  Givin at induction of anaesthesia.  The choice of an antibiotic depends on the expected spectrum of organisms likely to be encountered.  Patients with known valvular disease of the heart, prophylactic antibiotics during dental, urological or open viscus surgery.
  18. 18. 2.Preoperative preparation  Short preoperative hospital stay lowers the risk of acquiring infection.  Medical staff should always wash their hands between patients.  personal hygiene is vital.  Staff with open, infected skin lesions should not enter the operating theatres.  Antiseptic baths.  Preoperative shaving immediate before surgery.
  19. 19. 3.Scrubbing and skin preparation  Aqueous antiseptics should be used, and the scrub should include the nails, washing to the elbows e.g. Betadine or alcohol.
  20. 20. 4.Intra-Operative care  Numbers of staff in the theatre and movement in and out of theatre should be kept to a minimum.  dead spaces and haematomas should be avoided and the use of diathermy kept to a minimum.
  21. 21. Postoperative care of wounds  Tissue or pus for culture should be taken before antibiotic cover is started.  The choice of antibiotics is empirical until sensitivities are available.  Wounds are best managed by delayed primary or secondary closure.
  22. 22. The use of Anti-microbials  The use of antibiotics for the treatment of established surgical infection ideally requires recognition and determination of the sensitivities of the causative organisms.  choice being empirical and later modified depending on microbiological findings.  Drainage of pus should not be delayed.
  23. 23. Types of antibiotics use  A narrow-spectrum antibiotic may be used to treat a known sensitive infection.  Combinations of broad-spectrum antibiotics can be used when the organism is not known.
  24. 24. Precautions In HIV Patients • Use of a full face mask ideally, or protective spectacles. • use of fully waterproof, disposable gowns and drapes • boots to be worn, not clogs, to avoid injury from dropped sharps; • double gloving needed • allow only essential personnel in theatre; • avoid unnecessary movement in theatre; • respect is required for sharps, with passage in a kidney dish; • a slow meticulous operative technique is needed with minimised bleeding.