Surgical infection

1. Presented by Mr Magdi Siddig
January 2023

2. Over view:
 Surgical infection is major problem in surgical
practice.
 protective mechanisms:
Epithelial surfaces act as mechanical barrier and
phagocytes, antibodies; complements, macrophages,
leukocytes, opsonins.

3. risk factors for surgical infections.
 Malnutrition.
 Diabetes mellitus.
 Obesity.
 Uraemia.
 Jaundice.
Malignancy.
 Immunosuppression.
 Other {Radiotherapy, Chemotherapy, HIV, Ischaemia,
Foreign body, haematoma} .

4. Types of surgical infection
 Surgical infection can be classified in to:
{1} Superficial surgical site infection: in skin or
subcutaneous site.
{2} Deep surgical site infection: in deeper
fasciomuscular layers or organ space like abdomen/
thoracic cavity.

5. Southampton wound grading system for healing
and infection:
Grade 0 is normal healing.
Grade 1 is with bruising/mild erythema.
Grade 2 is severe erythema with other features of
inflammation at or around wound.
Grade 3 is serous or bloody discharge.
Grade 4 is presence of pus or deep infection or tissue
breakdown or significant haematoma.

6. CELLULITIS
 ♦ It is spreading inflammation of subcutaneous and
fascial planes.
♦ Infection may follow a small scratch or wound or
incision or insect/snake/scorpion bite.

7. Causative Agents
 Commonly due to Streptococcus pyogenes and
other Gram +ve organisms.
 Often Gram –ve organisms like Klebsiella, Pseudo
monas, E. coli.
 Usually Gram –ve organisms cause secondary
infection.

8.  Cellulitis can be:
 superficial or
 deep.
 More common superficial type which easier to
diagnose.
 It is common in DM, immunosuppressed and old age.
 Common in face, lower limb, upper limb and scrotum .

11. Clinical Features
♦ Fever.
♦ Toxicity (tachycardia, hypotension).
♦ Swelling is diffuse and spreading in nature.
♦ Pain and tenderness, red, shiny area with stretched
warm skin.
♦ Tender regional lymph nodes may be palpable which
signify severity of the infection.
♦ No edge; no pus; no fluctuation; no limit.

12. Investigation:
 CBC.
 UA.
 RBG.
 CRP.
 U/S -/+ Doppler ( if need).

13. Management
 Elevation of limb or part to reduce oedema.
 Antibiotics — penicillins, cephalosporins.
 Analgesia.
 Dressing.
 Bandaging.
 Topical.

14. Sequelae
♦ Infection can get localised to form pyogenic
abscess.
♦ Infection can spread to cause bacteraemia,
septicaemia.
♦ Often infection can lead to local gangrene.
♦ Extensive necrosis of skin and subcutaneous
tissue—necrotizing fascitis.

15. Ludwig’s Angina
 It is cellulites' of upper part of the neck.
 Involving submandibular region and floor of the
mouth along the fascial planes.
 It may be precipitated by tooth extraction, oral
cancer, submandibular gland infection, diabetes
mellitus, chemotherapy.

16. Clinical Features
♦ Diffuse swelling, redness, tenderness and induration
in the floor of the mouth and submandibular region.
♦ Trismus.
♦ Toxic features like fever, tachycardia and
tachypnoea.
♦ Severe laryngeal oedema (presents with
respiratory distress, stridor and cyanosis).
♦ Dysphagia.

17. Dangerous area of face—area of upper lip and lower part
of nose. Infection spreads through deep facial vein → pterygoid plexus →
communicating vein → cavernous sinus causing its life-threatening thrombosis.

19. Abscess

20. Pyogenic Abscess
 Definition:
It is a localised collection of pus in a cavity lined by
granulation tissue, covered by pyogenic membrane.
 It contains pus in loculi.
 Pus contains dead WBC’s, multiplying bacteria, toxins
and necrotic material.
 Protein exudation causes fibrin deposition and
formation of pyogenic membrane.

21. ♦ Macrophages and polymorphs release lysosomal
enzymes which cause liquefaction of tissues leading
into pus formation.
♦ Toxins and enzymes released causes tissue
destruction and pus formation.

26. Clinical Features of abscess
♦ Fever often with chills and rigors.
♦ Localized swelling which is smooth, soft and
fluctuant.
♦ Visible (pointing) pus.
♦ Throbbing pain and pointing tenderness.
♦ Brawny induration around.
♦ Redness and warmth with restricted movement
around a joint.
(Commonly cellulitis occurs first which eventually gets
localized to form an abscess.)

27. Sites of Abscess
A. External Sites
♦ Fingers and hand.
♦ Neck.
♦ Axilla.
♦ Breast.
♦ Foot, thigh—here it is deeply situated with brawny
induration.
♦ Ischiorectal and perianal region.
♦ Abdominal wall.
♦ Dental abscess, tonsillar abscess and other abscesses in
the oral cavity.

28. B. Internal Abscess
Abdominal:
♦ Intraperitoneal: Subphrenic, pelvic, paracolic,
amoebic liver abscess, pyogenic abscess of liver, splenic
abscess, pancreatic abscess.
♦ Perinephric abscess.
♦ Retroperitoneal abscess.
♦ Lung abscess.
♦ Brain abscess.
♦ Retropharyngeal abscess.

29. Investigations
♦ Total count is increased.
♦ Urine sugar and blood sugar is done to rule out
diabetes.
♦ U/S of the part or abdomen or other region is done
when required.
♦ Chest X-ray in case of lung abscess.
♦ CT scan or MRI is done in cases of brain and
thoracic abscess.

30. Treatment:
 After formed abscess.
 Incision and drain under either regional or general
anaesthesia.
 swab for C&S.
 Never give antibiotic only with surgery jn formed
abscess?!!!!
 Because a fried from formed,,,

31. antibioma

32. Complications of an Abscess
♦ Bacteraemia, septicaemia, and pyaemia.
♦ Multiple abscess formation.
♦ Metastatic abscess.
♦ Destruction of tissues.
♦ Antibioma formation (common in breast abscess).
Antibioma should be excised.

33. Contue….
♦ Sinus and fistula formation.
♦ Large abscess may erode into adjacent vessels and can
cause life-threatening torrential haemorrhage, e.g. as in
pancreatic abscess.
♦ Abscess in head and neck region can cause laryngeal
oedema, stridor and dysphagia.

34. Specific complications of internal abscess:
Brain abscess can cause intracranial hypertension,
epilepsy, neurological deficit.
Liver abscess can cause hepatic failure, rupture,
jaundice.
Lung abscess can lead to bronchopleural fistula or
septicaemia or respiratory failure or ARDS.

37. BACTERAEMIA
 Presence of bacteria in blood.

38. Septicaemia
Presence of overwhelming and multiplying bacteria in
blood with toxins causing SIRS (Systemic inflam
matory response syndrome) or
MODS (Multiorgan dysfunction syndrome).

39. Types of Septicaemia:
A. Gram +ve septicaemia:
Is due to staphylococci, streptococci, pneumococci.
It is common in children, old age, diabetics and after
splenectomy.
After splenectomy, overwhelming post-splenectomy
sepsis (OPSI) is not uncommon.
Common origin is skin, respiratory infection.

40. B. Gram –ve septicaemia
 Is common in acute abdomen like peritonitis, abscess,
urinary infections, biliary infections, postoperative
sepsis.
 It is commonly seen in malnutrition, old age,
diabetics, immunosuppressed people.
 Common bacteria are E. coli, Klebsiella, Pseudomonas,
Proteus.
 Condition is also called endotoxic shock.

41. Stages of Gram-negative Septicaemia
1. Warm stage is reversible stage. Here existing fever is
due to pyrogenic response. Patient is toxic with fever,
chills and rigors.
2. Cold stage is irreversible stage. Here fever is not
present due to absence of pyrogenic response. Patient
is having renal failure, ARDS, liver failure and multi-
organ failure.

42. Investigations
♦ Urine/pus/discharge culture.
♦ Blood culture.
♦ Haematocrit.
♦ Electrolyte assessment.
♦ PO2 and PCO2 analysis.
♦ Blood urea, serum creatinine, liver function tests.

43. Treatment

♦ Antibiotics ( like cefoperazone, ceftazidime, cefotaxime,
amikacin, tobramycin, metronidazole) .
♦ Fresh blood.
♦ Adequate hydration.
♦ Oxygen supplementation.
♦ Ventilatory support.
♦ Electrolyte management.
♦ Parenteral nutrition (TPN).
♦ CVP line for monitoring and perfusion.
♦ FFP or platelets in case of DIC.

45. PYOGENIC GRANULOMA :
 It is a common condition which occurs on the face,
scalp, fingers and toes.
♦ It may be due to minor trauma or minor infection.
♦ Infection leads to formation of unhealthy granu
lation tissue which protrudes through the wound.
It is also called as acquired lobular capillary
haemangioma.

46. Clinical Features
♦ Usually single, well localised, red, firm, nodule,
which bleeds on touch.
♦ May or may not be tender.

51. Thank you