Surgical Infections

Surgical Infections

Wound infection- invasion of organism

through tissue following breakdown of local
and systemic defenses

Surgical infections may arise in the surgical

wound itself or in other systems in the
patient.
 Kochspostulates
Infective organisms must be found in
considerable no. in septic foci
Possible to culture in pure form
It should be able to produce similar lesion when
injected in another host
 Protective mechanism
Mechanical barrier
Chemical low gastric ph
Humoral- antibodies, complement, opsonins
Cellular- phagocytes, macrophages, pmn and
killer cells
 Some definitions
Colonization:
presence of bacteria in a wound with no signs or
symptoms of systemic inflammation . usually bacterial
count less than 10*5cfu/ml
Contamination:
Transient exposure of a wound to bacteria.
Varying concentration of bacteria possible.
Time of exposure less than 6 hours.

Infection:
systemic and local signs of inflammation,
bacterial count more than 10*5cfu/ml
 Definition
Bacteraemia is unusual following superficial SSI
but common after anastomotic break down.
dangerous if the patient has prothesis.
 Causes of reduced host
resistance to infection

Metabolic- malnutrition, obesity, diabetes,

ureamia, jaundice
Disseminated disease- cancer, AIDS
Iatrogenic- radiotherapy, chemotherapy, steroids
 Risk factors for increased
wound infection
Malnutriton- obesity,weight loss
Metabolic diseases- diabetes, ureamia,
jaundice
Immunosupression-cancer, AIDS, steroids,
chemotherapy,radiotherapy
Colonisation and translocation in G.I. tract
Poor perfusion- shock
Foreign body material
Poor surgical technique
 Physiology
Suspended Enteral feeding during perioperative
period with underlying disease
Colonisation of gram negative bacilli in gut
Translocation to mesenteric lymph nodes
Release of endotoxins,
Activation of macrophages and cytokines release
Sirs and MODS
 SIRS
SIRS is the body's response to
infected wound

Two of
Hyperthermia >38 degree C or hypothermia <36
Tachycardia (>90) or tachypnoea(>20/min)
White cell >12x10 9 or < 4 x 10 9/l
 Sepsis- systemic manifestation of SIRS with
documented infection; common after anastomotic
breakdown
Severe sepsis or severe sepsis syndrome-
sepsis with one or more than one organ failure
MODS is the effect the infection produces
systemically
MSOF is the end stage of uncontrolled MODS

Sepsis may be associated with MODS

 Surgical Infections
Two main types

1. Community-Acquired - primary
active process that were initiated before the patient
presented for treatment
acquired from community or endogenous

2. Hospital-Acquired- Secondary
All infections that occur after surgical procedures
acquired from hospital or exogenous
 Community-Acquired
Skin/soft tissue
Cellulitis: Group A strep Tetanus
Abscess/furuncle: Hand infections
Staph aureus Foot infections
Necrotizing: Mixed Biliary tract
Hiradenitis infections
suppurativa: Staph Peritonitis
aureus
Viral infections
Lymphangitis: Staph
aureus
Gangrene : synergistic
 Hospital-Acquired
SSI (Wound infection)
Pulmonary
Urinary Tract
Intra-abdominal
Empyema
Foreign-body associated
Fungal infection
Multiple organ failure
Cellulitis
Spreading
inflammation of
subcutaneous and
fascial plane

Streptococcus
pyogenes, others-
klebsiella,
pseudomonas, E.coli
Furuncle
Acute staphylococcal
infection of hair
follicles with
perifolliculitis
suppuration and
central necrosis
Hiradenitis
Chronic infective and
fibrous disease of skin
bearing apocrine
gland which ones into
hair follicles
Sites of apocrine
sweat glands
Axilla,areola,umbilicus
,
groin, perineum
 Carbuncle
Charcoal
Infective gangrene of skin and subcutaneous
tissues
Staphylococcus aureus main culprit
Nape of neck and back
Common in diabetic
Necrotizing
Spreading
inflammation of the
skin, deep fascia and
soft tissues with
extensive tissue
destruction
 80% polymicrobial- streptococcus pyogenes
,coliform, gram negative organism, anaerobes
Limbs, lower abdomen, groin, perineum
Common in old age, smoking, diabetics,
immunotherapy and Hiv patients.
Trauma is a common precipitating factor
 Clinical features
Sudden swelling, pain in the part with oedema
Foul smelling discharge
Crepitus with subcutaneous emphysemas, skin
vesicles, extensive necrosis and cutaneous
microvascular thrombosis
Oliguria
Jaundice
Toxemia, sirs, MODS,
 Management
IV fluids,
Antibiotics
Resuscitation, critical care ( oxygen, intubation
and ventilator
Wound excision
Skin grafting
Lymphangitis
Non supperative and
poorly localised
Painful red streaks in
affected lymphatics
Often accompanied by
painful lymph nodes
 Cellulitis and lymphangitis
Non-suppurative , poorly localized
Commonly caused by streptococci, staphylococci
or clostridia
SIRS is common
Blood cultures are often negative
 Abscess
Localized collection of pus in a cavity lined by
granulation tissues
Pus- dead wbcs , multipying bacteria, toxins and
necrotic material
 abscess
Staphyloccus aureus
Streptococcus pyogenes
Gram negative bacteria
anaerobes
 Factors precipitating abscess
formation
General condition of pt
Associated disease
Types of organism
Others- trauma,
 Complication of abscess
Bacteremia
septicaemia
pyaemia
Antibioma
Sinus and fistula formation
Specific complication
 Abscesses
Abscesses need drainage and curettage
Modern imaging technique may allow guided
aspiration
Antibiotics if not localised
Healing by secondary intention is better
Gas gangrene
Caused by Clostridium
perfringens
Gas and smell are
characteristic
Immunocompromised
patients are most at
risk
Antibiotic prophylaxis
is essential when
performing
amputation
 Surgical Site Infection
SSI is an infected wound or deep organ
space

an infection that is present up to 30 days

after a surgical procedure if no implants are
placed, and up to one year if an implantable
device was placed in the patient

The majority of SSIs will occur during the

first 2-3 weeks after surgery
 Types
1. Major- significant pus or needs secondary
procedure to drain it
Tachycardia, pyrexia or raised cbc

2. Minor- may discharge pus but not associated

with excessive discomfort , systemic signs or
delayed return
Asepsis scoring system for severity of wound
infection
 Types of Surgical Site Infections

According to the tissue involved:

1. Superficial
2. Deep incisional
3. Organ/space
 Superficial incisional SSI :

Infection occurs within 30 days after the operative procedure

and
involves only skin and subcutaneous tissue of the incision
and

patient has at least one of the following:

a. purulent drainage from the superficial incision.
b. organisms isolated from an aseptically obtained culture of fluid or
tissue from the superficial incision.
c. at least one of the following signs or symptoms of infection: pain
or tenderness, localized swelling, redness, or heat, and superficial
incision are deliberately opened by surgeon, and are culture-
positive or not cultured. A culture-negative finding does not meet
this criterion.
d. diagnosis of superficial incisional SSI by the surgeon or attending
physician.
 A deep incisional SSI must meet one of
the following criteria:

Infection occurs within 30 days after the operative procedure if no

implant is left in place or within one year if implant is in place and
the infection appears to be related to the operative procedure
and
involves deep soft tissues (e.g., fascial and muscle layers) of the
incision
and
patient has at least one of the following:
a. purulent drainage from the deep incision but not from the organ/space
component of the surgical site
b. a deep incision spontaneously dehisces or is deliberately opened by a
surgeon and is culture-positive or not cultured and the patient has at
least one of the following signs or symptoms: fever (>38C), or
localized pain or tenderness. A culture-negative finding does not meet
this criterion.
c. an abscess or other evidence of infection involving the deep incision is
found on direct examination, during reoperation, or by histopathologic
or radiologic examination
d. diagnosis of a deep incisional SSI by a surgeon or attending physician.
 An organ/space SSI must meet one of the
following criteria:

Infection occurs within 30 days after the operative procedure if no

implant is left in place or within one year if implant is in place and
the infection appears to be related to the operative procedure
infection involves any part of the body, excluding the skin incision,
fascia, or muscle layers, that is opened or manipulated during the
operative procedure
and
patient has at least one of the following:
a. purulent drainage from a drain that is placed through a stab wound into
the organ/space
b. organisms isolated from an aseptically obtained culture of fluid or
tissue in the organ/space
c. an abscess or other evidence of infection involving the organ/space that
is found on direct examination, during reoperation, or by
histopathologic or radiologic examination
d. diagnosis of an organ/space SSI by a surgeon or attending physician.
 Source of SSI Pathogens
1. Endogenous flora of the patient

2. Operating theater environment

3. Hospital personnel (doctors/nurses/staff)

4. Seeding of the operative site from distant focus of

infection (prosthetic device, implants)
 Pathogenesis of SSI
Relationship equation

Dose of bacterial contamination x

Virulence Resistance of
host

SSI RISK
 Risk factors
1. surgical factors
A. Type of procedure
B. Degree of contamination
C. Duration of operation
D. Urgency of operation

2. Patient-specific factors
Patient-specific factors can be further defined as
either local and systemic
 Patient-specific factors

local systemic
High bacterial load Advanced age
Wound hematoma Shock
Necrotic tissue Diabetes
Foreign body Malnutrition
Obesity Alcoholism
Steroids
Chemotherapy
Immuno-
compromise
 Wound Classification
according to the degree of contamination
 Determinants of the
infection
Every surgical site is contaminated by bacteria at the
end of the procedure, few become clinically infected.
Important determinants lead to either uneventful wound
healing or SSI.

1. Inoculums of the bacteria

2. Virulence of the bacteria
3. Integrity of host defenses (Innate and acquired )
4. Effects of microenvironment
 1. Inoculum of the bacteria

Sources:
Air in operation room
Instruments
Surgeons and staff
Patients flora. Largest inoculum is from areas that are
heavily colonized e.g. bowel, female GUT, diseased
biliary tract
This factor is modifiable
 2. Virulence of the bacteria

The more virulence the bacteria, the

greater probability of infection
Coagulase positive staph
Virulent strain of perfiringens and group A streptococi
E coli
Bacteroids
This factor can not easily be controlled by preventive
strategies because it is intrinsic to the procedural site and
the type of bacteria that already colonize the patient
 3. Effects of microenvironment

The following factors in the microenviroment of the

wound predispose to SSI
Necrotic tissue
Hb at the surgical site
FB, drains
Dead space with in the surgical site
Surgical techniques
Vascularity and health of tissues
Presence of dead and foreign body
Presence of antibiotics during decisive
 4. Integrity of host defenses

Innate host defense deficiency

Acquired host defense deficiency
Shock and hypoxia
Transfusion
Chronic illness
Hypoalbuminaemia
Malnutrition
Hypothermia
Hyperglycemia
Corticosteroids
Obesity
Nicotine use
chemotherapy
 Prevention of SSI
1. Preoperative planning
2. Intra operative technique
3. Preventive antibiotic therapy
4. Enhancement of host defense
 1. Preoperative planning
Control preexisting infection of patient

Postpone the operation if open skin wound or hand infection

of surgeon present

Decrease preoperative hospitalization period

Shower and scrub the surgical site with antiseptic soap the
evening prior to operation

Clipping the hair from surgical site before the operation

 2. Intra operative technique
Skin preparation Avoid dead space

Caps, masks gowns, surgical Insert drains through separate

gloves stab incision

Sterilization of the Leave skin and subcutaneous

instruments tissue open if dirty

Sterile dressing
Gentle handling of tissue
Topical ointments
Good haemostasis
3. Preventive antibiotic therapy
Emperical cover against expected pathogens till
sensitivities available
Tissues or pus sent for culture prior to that
Single shot antibiotics at the time of induction of
-
Repeat IV only in prosthetic surgery, long
surgery(if excessive blood loss) Repeated 8 hrs
and 16 hrs later
Continue if unexpected contamination
Benzylpenicillin if suspected clostridium
infection
4. Enhancement of host defense
1. Increase oxygen delivery
2. Optimizing core body temperature
3. Blood glucose control
4. Correct any coexisting condition e.g
malnutrition, anemia
Advances in control of infection
in surgery
Aseptic operating theatres
Antibiotics have reduced the post operative
infection rates in elective and emergency cases
Techniques of delayed /secondary closures remain
useful in contaminated wounds
 Choice of antibiotics for
prophylaxis
Empirical coverage against expected
pathogens with local hospital
guidelines
Single shot IV at induction
 Avoiding surgical site
infections
Wash hands between patients
Minimal patients stay
Avoiding preoperative shaving
Standard antiseptic skin preparation
Attention to theatre techniques and
decipline
Avoid hypothermia preoperatively and
ensure supplemental oxygenation in
recovery