Surgical Infections slide share ppt

Seminar on Surgical infections
Prepared By: Dr. Atinkut Abesha
Moderator: Dr. Tilahun (G.Surgeon)
Date: 19/11/2014 E.C
1 Surgical Infections: Prepared By: Atinkut A. (Medical Intern)

Outlines
2
Host defence mechanisms
Definition of Surgical Infections
Etiologies of Surgical infections
Classification of surgical infections
Surgical Site infections
Factors affecting SSIs
Clinical features of SSIs
Surgical infections other than SSIs
Prevention and treatments of surgical infections
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)

Objectives
3
To know the defensive mechanisms of our body
to infections
To define what surgical infections mean
To describe different surgical infections
To know different factors affecting surgical
infections
To know how to prevent and treat surgical
infections
Surgical Infections: Prepared By:
Atinkut A. (Medical Intern)

Surgical Infections… Introduction
4
Host Defense Mechanisms
The host possesses several layers of endogenous
defense mechanisms that serve to prevent
microbial invasion, limit proliferation of microbes
within the host, and contain or eradicate invading
microbes.

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Host Defense Mechanisms:
Integumentary barrier
Mucosal surfaces (respiratory, gut, and
urogenital)
Colonization resistance
Defenses (phagocytosis, fibrinogen, iron
sequestration,)
Components that freely circulate throughout
the body

6

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The magnitude of the response and eventual outcome
is generally related to several factors:
The initial number of microbes,
The rate of microbial proliferation
Microbial virulence
The potency of host defenses
Outcomes
eradicati
on
containm
ent
Regional
infection
Systemi
c
infection

Surgical Infections… Definition
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Definition of Surgical Infections:
Infection: The presence of microorganisms in host
tissue or the bloodstream
Surgical infections:
 Infections that develop following surgery or
traumatic injury
 Infections that require surgical treatment for their
cure

Surgical Infections… Etiologies

Surgical Infections… Route of infection
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Route of infection:
Direct inoculation
Airborne contamination
Haematogenous/lymphatic seeding

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Surgical
infections other
than SSIs

I. Surgical Site Infections
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Infections of the tissues, organs, or spaces
exposed by surgeons during performance of an
invasive procedure
Time of infection:
Within 30 days of surgery with out implant
Within one year of surgery with implant

I. Surgical wound…Classification
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Based on the presumed magnitude of the
bacterial load at the time of surgery:
Clean wounds (class I)
Clean/contaminated wounds (class II)
Contaminated wounds (class III)
Dirty wounds (class IV)

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Wound class Rate of infection
with prophylaxis
(%)
Infection rate with
prophylaxis (%)
Clean (no viscus opened) 1-2 1-2
Clean contaminated (viscus
opened, minimal spillage )
3 6-9
Contaminated (open viscus
with spillage or
inflammatory disease )
6 13-20
Dirty (pus or perforation,
or incision through an
abscess)
7 40

I. Surgical Site Infections…Classification
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Classification of Surgical Site infections: based on
depth/involved organ
Incisional (superficial, Deep)
Organ/space infections

Classification of Surgical Site infections:

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Classification of Surgical Site infections:
I. Major SSI;
Significant quantities of pus spontaneously
Needs procedure to drain it
Patients are systemically ill
Delayed return to home

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Classification of Surgical Site infections:
II. Minor SSI
May discharge pus or infected serous fluid
But, are not associated with excessive discomfort,
systemic signs or delay in return to home

I. Surgical Site Infections…Risk factors
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Risk factors for development of surgical site
infections:
Microbial
factors Local factors

Patient factors
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Older age
Immunosuppression
Obesity
Diabetes mellitus
Chronic
inflammatory
process
Malnutrition
Smoking
Renal failure
Peripheral vascular
disease
Anemia
Radiation
Chronic skin disease
Carrier state
Recent operation

Local factors
Surgical Infections: Prepared By: Atinkut A. (Medical
Intern)
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Open compared to laparoscopic surgery
Poor skin preparation
Contamination of instruments
Inadequate antibiotic prophylaxis
Prolonged procedure
Local tissue necrosis
Blood transfusion
Hypoxia, hypothermia

Surgical Infections: Prepared By: Atinkut A. (Medical
Intern)
24
Microbial factors
Prolonged hospitalization (leading to
nosocomial organisms)
Toxin secretion
Resistance to clearance (e.g., capsule
formation)

I. Surgical Site Infections…C/F
25
Clinical features of Surgical infections:
Pain
Tenderness
Localized swelling
Redness
Hotness
Purulent discharge

I. Surgical Site Infections…Diagnosis
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Diagnosis:
Purulent drainage
Isolation of organisms
Any one of sign and symptoms of infection
Diagnosed by operating surgeon/ found on
reoperation
Spontaneously dehisced fascia with at least one S
& S of inflammation
An abscess or other evidence of infection involving
the organ/space

I. Surgical Site Infections…Treatment
27
SSI treatment:
I. Treatments of Incisional SSIs:
Incision and drainage without the additional use of
antibiotics.
Antibiotic therapy is reserved for patients in whom
evidence of significant cellulitis is present
The open wound often is allowed to heal by
secondary intention

28
SSI treatment:
II. Treatments of Organ/space SSIs:
Source control to resect or repair the diseased organ
Debridement of necrotic, infected tissue and debris
Administration of antimicrobial agents directed
against aerobes and anaerobes

29
SSI treatment:
If Patients in whom the above standard therapy
fails, typically develop one or more of the
following;
Intra-abdominal abscess
Leakage from a gastrointestinal anastomosis
leading to postoperative persistent peritonitis

30
SSI treatment:
For Intra abdominal abscess:
Drained percutaneously
Surgical intervention is reserved for;
 Those individuals who harbour multiple abscesses
 Those with abscesses in proximity to vital structures
 Those in whom an ongoing source of contamination

I. Surgical Site Infections…Prevention
31
SSI prevention: In general, control the risk factors
Preoperative measures:
Short preoperative hospital stay
Preoperative showering
Treat remote site infections
Optimize nutrition status
Optimize the glucose level
Stop smoking
Prophylactic antibiotic

32
SSI prevention:
Intraoperative measures:
Follow aseptic technique
Avoid spillage
Complete debridement
Appropriate Surgical technique
Limit use of sutures/foreign bodies

33
SSI prevention:
Postoperative measures:
Protect incision for 48-72 hours
Remove drains as soon as possible
Wearing protective sterile gloves during
examination
Early enteral nutrition
Tight glucose control

II. Surgical Infections other than SSIs
34
Infections that require surgical treatment for their
cure
 Cellulitis
 Erysipelas
 Abscess
 Pyomyositis
 Necrotizing fasciitis
 Ludwig’s Angina

1. Cellulitis 2. Erysipelas
35
Skin and subcutaneous
infections
Streptococcus and
staphylococcus
Usually unilateral
R/F;
Anything that causes break
in the skin
Inflammatory skin
condition
Skin (upper dermis) and
superficial lymphatic
infections
Streptococcus and
staphylococcus
Usually unilateral
R/F;
Anything that causes break
in the skin
Inflammatory skin condition

1. Cellulitis 2. Erysipelas
36
Edema from CVI/impared
lymphatic drainage
Immunosuppression
Indolent onset
Erythematous, edematous,
Hot skin
No clear demarcated
boarder
Edema from
CVI/impared lymphatic
drainage
Immunosuppression
Acute in onset
Erythematous,
edematous, Hot skin
Clear demarcated
boarder

37
Cellulitis/Erysipelas:
Treatment
 Bed rest with legs elevated
Appropriate antibiotics

38
Cellulitis/Erysipelas:
Complications
Abscess
Necrotising fasciitis
Toxaemia and septicaemia
Precipitate ketoacidosis in a patient who has
diabetes mellitus

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3. Abscess:
 Localised collection of pus (dead and dying
neutrophils plus proteinaceous exudate).
Trauma, Immunocompromised conditions, IV drug
abusers are often affected
Pyogenic abscess
Pyaemic abscess
Cold abscess

40
I. Pyogenic abscess:
Intense inflammation that tend to stimulate acute
inflammation which is caused by bacteria
Staphylococcal infections
 Route of infections;
External wound
Haematogenous
Previous untreated cellulitis
Encircled by fibrin products

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I. Pyogenic abscess:
C/F:
Hotness
Redness
Swelling
Loss of function
Throbbing pain
Fluctuant mass

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I. Pyogenic abscess
Treatments:
Incision and drainage
Then, appropriate antibiotics for 5-7 days

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I. Pyogenic abscess
Pyomyositis:
Localised area of suppuration within striated
muscle
Quadriceps, gluteus, shoulder and upper arm
muscle are affected
Pain over the part oedema, fever, tenderness,
induration and spasm of the affected muscle
Renal failure follows soon

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I. Pyogenic abscess
Pyomyositis: Stages
 Stage of cellulitis
Stage of Abscess
Stage of sepsis

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I. Pyogenic abscess
Pyomyositis treatment
 Early diagnosis and early aggressive treatment
Antibiotics
Exploration-for diagnosis and as a treatment
Wide excision of muscles and compartmental
excision till viable tissues are visible

46
II. Pyaemic abscess:
Occurs due to circulation of pyaemic emboli in
the blood
Due to pus-producing organisms in the
circulation
Commonly occurs in diabetics and patients
receiving chemotherapy and radiotherapy
Characterised by following features; multiple,
deep-seated, minimal tenderness, Local rise of
temperature is not present

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II. Pyaemic abscess:
Treatments:
Multiple incisions over the abscess site and
drainage
Then, appropriate antibiotics for 5-7 days

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III. Cold abscess:
Lacks the intense inflammation usually associated
with infection that do not tend to stimulate acute
inflammation
Has no signs of inflammation
Causes are TB, Leprosy, Actinomycosis

49
III. Cold abscess:
Treatments
Anti tuberculosis regimen/leprosy
Excision

50
4. Necrotizing fasciitis
It is a spreading, destructive, invasive infection of
skin and soft tissues including deep fascia with
relative sparing of muscle
Common sites: lower extremities, genitalia, groin,
lower abdomen
Risk factors: DM, Malnutrition, obesity,
immunosuppression conditions

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Type I necrotising fasciitis: Polymicrobial
Type II necrotising fasciitis: Monomicrobial

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Clinical Features:
Sudden pain in the affected area
Gross swelling of the limbs
Redness
erythematous
Skin necrosis and ulceration
High degree fever, jaundice, renal failure can
occur soon in untreated cases

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Treatments:
Early, aggressive treatment includes supportive
and surgical treatment
Hospitalisation
Adequate hydration
broad spectrum antibiotics
wide excision, generous debridement followed by
skin grafting, a few days or weeks later

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5. Ludwig’s Angina
Cellulitis of submental and submandibular regions
combined with inflammatory edema of the mouth.
Causative agents: streptococcal and anerobic
microbes
Risk factors: Caries tooth, Cancer of the oral
cavity, Calculi in the submandibular gland,
Chemotherapy, Cachexia and Chronic disease (6
Cs)

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Clinical Features:
Diffuse swelling in the submandibular and
submental region
Edema of the floor of the mouth
High grade fever with toxicity
Putrid halitosis
Dysphagia/odynophagia/drooling

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Complication
Compromise airway
Septicemia

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Treatments:
Rest
Hospitalisation
Appropriate antibiotics
IV fluids to correct dehydration
Tube feeding
Surgical intervention

References
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Schwartz's Principles of Surgery 11th edition
Bailey & Loves Short Practice of Surgery 27th
edition
Manipal Manual Of Surgery 4th Edition
Uptodate

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