surgical infection chapter two

1. Surgical Infection
Chapter Two

3. • The classical inflammatory response
resulting in the clinical features of
infection (the cardinal signs of
infection):
• Rubor (redness);
• Tumor (swelling);
• Dolor (pain);
• Calor (heat).

4. • In acute infection these clinical
features may be accompanied by
swinging pyrexia, leukocytosis, raised
C-reactive protein.
• Resolution: If tissue damage is
minimal, the inflammatory response
settles completely and the tissue
returns to normal

5. Spreading infection:
• By direct spread into adjacent tissues;
• Along tissue planes, e.g. tendon sheaths;
• Via the lymphatic channels, producing the
characteristic red lines of lymphangitis and
enlarged tender lymph nodes (acute
lymphadenitis); or
• Via the bloodstream, causing bacteraemia
(presence of bacteria in the blood) or
septicaemia (presence of propagating
organisms in the blood).

6. • Abscess formation:
• Organization: Following acute
inflammation with tissue damage or
drainage of an abscess, repair of the
tissues is achieved by organization,
formation of granulation tissue and
fibrosis.
• Chronic inflammation

7. Management of infection
• Prevention of infection
• Management of established
infection

8. Prevention of infection:
Prophylaxis is always better than cure.

9. 1. The risk of certain complications varies
from procedure to procedure
2. Must be started before the operation or
procedure and be continued until the risk
period has passed
3. Effective and carry very little risk of it.
4. To prevent complications that are relatively
common
5. To prevent complications that are relatively
serious consequences
Principles of prophylaxis:

10. The following measures are known to
reduce infection rates:
• laparoscopic vs. open operations;
• skin cleansing/disinfection;
• surgical masks and impervious surgical
microfibre gowns;
• Preoperative shaving should be
avoided if possible
• Avoid hypothermia perioperatively and
ensure supplemental O2 in the
recovery
• Prophylactic antibiotics.

13. Prophylactic antibiotics
If antibiotics are given empirically, they
should be used when local wound
defenses are not established
(the decisive period).
Ideally, maximal blood and tissue levels
should be present at the time at which
the first incision is made and before
contamination occurs.

14. Choice of antibiotics for prophylaxis
• Empirical cover against expected
pathogens with local hospital
guidelines
• Single-shot intravenous
administration at induction of
anaesthesia
• Repeat only in prosthetic surgery,
long operations or if there is excessive
blood loss

15. • Continue as therapy if there is
unexpected contamination
• Benzylpenicillin should be used if
Clostridium gas gangrene infection is a
possibility
• Patients with heart valve disease or a
prosthesis should be protected from
bacteraemia caused by dental work,
urethral instrumentation or visceral
surgery

16. Antiseptics commonly used in general
surgical practice:

17. Protection against AIDS and hepatitis
• There is no doubt that doctors and
nurses risk acquiring hepatitis
(especially hepatitis B infection) and
AIDS, but the risk is small especially if
suitable precautions are taken
• The infectivity of human
immunodeficiency virus (HIV) is much
less than that of hepatitis B virus

18. precautions are necessary
• avoid 'sharps' injuries
• Double gloving
• Avoidance of spillage of blood and body
secretions
• Labeling suspect blood specimens
• Use of disposable equipment
• All healthcare workers, including medical
students, are now vaccinated against
hepatitis

19. Tetanus prophylaxis
• Consideration of tetanus prophylaxis
depends upon the status of the wound and
immunization status of the patient

20. Prevention of hospital-acquired
infections
• Hospital-acquired infections with resistant
organisms, e.g. MRSA, cause significant
morbidity and mortality and add
considerably to the cost of care in severe
outbreaks, whole wards may need to be
closed

22. The principles governing prevention of
these infections
• strict adherence to hospital antibiotic
practice
• always washing hands after examining
a patient
• strict aseptic care of intravenous lines
• isolation of infected cases

23. Classifications of wound according to
rate of infection
1. Clean
2. Clean – Contaminated
3. Contaminated – Dirty

24. Management of established infection
• Diagnosis
• Antibiotic
• Drainage

25. Diagnosis
• The presence of an infection will be
suspected from the clinical picture.
Wherever possible, infected material should
be obtained for culture before commencing
antibiotics

26. Principles for the use of antibiotic
therapy
• Antibiotics do not replace surgical drainage
of infection
• Only spreading infection or signs of systemic
infection justifies the use of antibiotics
• Whenever possible, the organism and
sensitivity should be determined
• Prescribe on basis of culture results and
'most likely organism' while waiting for
results

27. • Certain antibiotics are reserved for
serious infections
• Therapeutic monitoring of drug levels
may be required, e.g. with
aminoglycosides
• Synergistic combinations may be
required in some infections, e.g.
aminoglycoside, cephalosporin and
metronidazole for faecal peritonitis
• In serious infections seek advice from
clinical bacteriologist

28. Antibiotic rotation

29. Drainage
• Drainage is essential once an abscess has
become established and antibiotics play only
a secondary role in the management.
Traditionally all abscesses were drained
surgically but nowadays many, including
intra-abdominal abscesses, are drained
percutaneously by interventional radiology
techniques with CT or ultrasound guidance.
Irrespective of approach, radiological or
surgical, the principle is the same: the pus
should be removed and a track established
for free drainage.

31. The following measures are known to
reduce infection rates:
• laparoscopic vs. open operations;
• skin cleansing/disinfection;
• surgical masks and impervious surgical
microfibre gowns;
• Preoperative shaving should be
avoided if possible
• Avoid hypothermia perioperatively and
ensure supplemental O2 in the
recovery
• Prophylactic antibiotics.

32. Prophylactic antibiotics
If antibiotics are given empirically, they
should be used when local wound
defenses are not established
(the decisive period).
Ideally, maximal blood and tissue levels
should be present at the time at which
the first incision is made and before
contamination occurs.

33. precautions from AIDS & hepatitis
• avoid 'sharps' injuries
• Double gloving
• Avoidance of spillage of blood and body
secretions
• Labeling suspect blood specimens
• Use of disposable equipment
• All healthcare workers, including medical
students, are now vaccinated against
hepatitis

34. Tetanus prophylaxis
• Consideration of tetanus prophylaxis
depends upon the status of the wound and
immunization status of the patient

35. The principles governing prevention of
these infections
• strict adherence to hospital antibiotic
practice
• always washing hands after examining
a patient
• strict aseptic care of intravenous lines
• isolation of infected cases

36. Classifications of wound according to
rate of infection
1. Clean
2. Clean – Contaminated
3. Contaminated – Dirty

37. Management of established infection
• Diagnosis
• Antibiotic
• Drainage

39. A 8 years child presenting with facial
cellulitis secondary to an odontogenic
infection
Your supervisor ask you to prescribe an
antibiotic coarse for him if the child
weight is 30 kg
Can you give me the 1st line Tx and the
correct dose ?

40. ‫تكن‬ ‫مل‬ ‫ذا‬‫ا‬ ‫نبةل‬‫س‬‫ل‬‫ا‬ ‫نحين‬‫ت‬ ‫وال‬‫مثقةل‬
‫ناء‬‫حن‬‫اال‬ ‫ساعة‬ ‫لكهنا‬‫و‬
‫اري‬‫و‬‫ت‬‫بقاء‬‫ل‬‫ا‬ ‫بذور‬