Surgical%20Infections

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Surgical Infections

• Under supervision of
• Dr. MOHAMMED AL-AKEELY

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infection

• Invasion of the body by pathogenic microorganisms
  and reaction of the host to organisms and their
  toxins

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• A surgical infection is an infection which
  requires surgical treatment and has developed
  befor, or as a complication of surgical treatment.

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• could be life threatening
• Accounts for 1/3 of surgical patients
• Increased cost to healthcare

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Some imp defin.

• Bacteremia bacteria in blood
• SIRS systemic inflammatory response syndrome
  (fever, tachycardia, tachypnea, leukocytosis)
• Sepsis documented infection SIRAS
• Septic shock sepsis hypotension refractory to
  fluid resuscitation

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Principles of surgical treatment

• Debridement- necrotic, injured, dead tissue
• Drainage- abscess, infected fluid
• Removal- infection source, foreign body
• Supportive measures
• immobilization
• elevation
• antibiotics

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Common organisms

• Gram positive bacteria
• Streptococci
• Staphylococci
• Clostridia
• Gram negative bacteria
• Pseudomonas
• E. coli
• Bacteroid fragilis

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Streptococcal infections

1. Cellulitis
2. Lymphangitis
3. Lymphadenitis
4. Necrotizing faciitis

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cellulitis

• severe inflammation of dermal and subcutaneous
  layers of the skin.
• caused by normal skin flora(group A strept
  /staph)or by exogenous bacteria.
• the bacteria can spread rapidly, entering the
  lymph nodes and the bloodstream and spreading
  throughout the body.
• In rare cases, the infection can spread to the
  deep layer of tissue (Necrotizing faciitis).
• often occurs in broken skin.

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cellulitis

• Signs symptoms affected area is red, hot, and
  tender with vague borders.
• Most common sites Face, hand and lower
  extremities.
• RF old age immunodeficiency.
• Diagnosis clinically.
• TX
• 1- resting, elevation of the affected limb,
  debridement.
• 2- ampicillin/amoxicillin in moderate (suspected
  strept) flucloxacillin or dicloxacillin for
  mild (staph)

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cellulitis
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Erysipelas

• Erysipelas is the term used for a more
  superficial infection of the dermis and upper
  subcutaneous layer that presents clinically with
  raised surface and well defined edge.
• Erysipelas and cellulitis often coexist, so it is
  often difficult to make a distinction between the
  two.

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Erysipelas
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Lymphangitis

• Lymphangitis is an inflammation of the lymphatic
  channels that occurs as a result of infection at
  a site distal to the channel.
• Streptococcus pyogenes.
• Signs and symptoms deep reddening of the skin,
  warmth, with moderate pain and swelling.
  Lymphadenitis, chills and a high fever along. (
  appears as red streak).

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Lymphangitis

• Tx
• 1-elevate and immobilize affected areas to reduce
  swelling, pain, and the spread of infection.
• 2- antibiotic.

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Lymphangitis
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LYMPHADENITIS

• Lymphadenitis is an infection of the lymph nodes.
• Lymphadenitis may occur after skin infections or
  other bacterial infections, particularly those
  due to streptococcus or staphylococcus.
• Swollen, tender, or hard lymph nodes
• Red, tender skin over lymph node
• Lymph nodes may feel rubbery if an abscess has
  formed.

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LYMPHADENITIS

• Treatment may include
• Antibiotics to treat any underlying infection
• Analgesics (pain killers) to control pain
• Anti-inflammatory medications to reduce
  inflammation and swelling
• Cool compresses to reduce inflammation and pain
• Surgery may be needed to drain any abscess.

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LYMPHADENITIS
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Necrotizing fasciitis (flesh-eating disease)

• Infection and necrosis of the deeper layers of
  skin and subcutaneous tissues.
• 2 types lpolymicrobial
• ll monomicrobial (mostly group
  A strept)
• Signs and symptoms The infection begins locally,
  at a site of traumagtgtintense paingtgt then tissue
  becomes swollen (hrs.)
• Common sites abdominal wall, perineum, and
  limbs.
• Diagnosis visual examination microscopic
  evaluation of tissue samples.

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Necrotizing fasciitis

• RF diabetes, abdominal surgery, drug addict and
  trauma.
• Tx
• 1-Early medical treatment (combination of
  intravenous antibiotics including penicillin,
  vancomycin, and clindamycin)
• 2-Cultures are taken to determine appropriate
  antibiotic
• 3-aggressive surgical debridement ( no
  definitive boundries!!)
• High mortality rate (75) if left untreated.

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Necrotizing fasciitis
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Staphylococcal Infections

• Abscess is a collection of pus (dead
  neutrophils) that has accumulated in a cavity
  formed by the tissue
• It is a defensive reaction of the tissue to
  prevent the spread of infectious materials to
  other parts of the body
• As Staphylococcus aureus bacteria is a common
  cause, an anti-staphylococcus antibiotic such as
  flucloxacillin or dicloxacillin is used
• Incision and drainage is a common surgical
  intervention in case of abscess

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Staphylococcal Infections

• Furuncle- infection of one hair follicle /
  sweat glands
• Carbuncle- extension of furuncle into subcut.
  Tissue with possible formation of abscess.
• usually more than one furuncle
• common in diabetic patient
• common sites- back, back of neck
• Treatment drainage, antibiotics, control
  diabetes

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Staphylococcal Infections
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Clostridial infections

• Gas gangrene
• Tetanus
• Pseudomembranous colitis

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GAS GANGRENE

• is a bacterial infection that produces gas in
  gangrenous tissues usually caused by Clostridium
  perfrengins bacteria.
• It is a medical emergency (Progression to
  toxemia and shock is often very rapid)
• Large wounds contaminated by soil.
• It results in rapid myonecrosis, swelling,
  seropurulent discharge, foul smelling wound,
  crepitus in subcutaneous tissue.

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GAS GANGRENE

• X-ray gas in muscle and under skin.
• Tx
• 1-Wound exposure, debridement , drainage.
• 2-Penicillin, clindamycin, metronidazole
• 3-Hyperbaric oxygen chamber

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GAS GANGRENE
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TETANUS

• Cl. Tetani, produce neurotoxin
• Penetrating wound ( rusty nail, thorn )
• Incubation period 7-10 days
• Usually wound healed when symptoms appear
• Trismus- first symptom, stiffness in neck back
• Anxious look with mouth drawn up ( risus
  sardonicus)
• Progressive dysphasia, dysphagia, dyspnea tonic
  convulsion
• Death by exhaustion, aspiration or asphyxiation

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TETANUS

• Treatment
• wound debridement
• Muscle relaxants, penicillin
• ventilatory support
• Prophylaxis
• vaccination by HTIG T toxoid in tetanus prone
  wound in patient with unknown or incomplete
  history of immunization.
• If it is more than 5 years since last dose of
  tetanus immunization give only T toxoid.

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PSEUDOMEMBRANOUS COLITIS

• Superinfection in patients in long term oral
  antibiotic therapy
• Cl. Difficile
• Watery diarrhea, abdominal pain, fever
• Diagnosis needs Sigmoidoscopy, stool- culture and
  toxin assay
• Treatment
• stop offending antibiotic
• oral vancomycin/
  metronidazole
• rehydration, isolate patient

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Pseudomonas

• Opportunestic bacteria that may cause surface
  infections, but may also cause serious and lethal
  infection.
• Enter the body through minor skin abrasion,
  ventilator tubes, urinary catheters and IV lines
  gtgtgt therefore it is common in ICU.
• Can cause septecimia (particularly in burn
  wounds)
• Tx aminoglycosides, piperacillin, ceftazidine.

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E. coli

• Normal intestinal flora, facultative anearobes.
• May cause circulatory collapse (due to
  endotoxin), wound infections, meningitis,
  endocarditis, abdominal abscess UTI.
• Tx ampicillin, aminoglycosides, cephalosporine.

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Bacteroides fragilis

• Normal flora of mouth and colon, anearobic.
• Produce foul smelling pus, gas in surrounding
  tissues necrosis.
• Responsible for intraabdominal gyne. infection.
• Causes spiking fever, jaundice leukocytosis.
• Tx
• Surgical drainage, excision.
• Clindamycin, metronidazole.

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Hospital aquired infections

• The most common is UTI
• The most common causing death is pneumonia.

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Surgical site infection (SSI)

• 38 of all surgical infections
• Infection within 30 days of operation
• Classification
• Superficial Superficial SSIinfection in
  subcutaneous plane (47)
• Deep Subfascial SSI- muscle plane (23)
• Organ/ space SSI- intra-abdominal,
  other spaces (30)
• Staph. aureus- most common organism
• E coli, Entercoccus ,other Entetobacteriaceae-
  deep infections
• B fragilis intrabd. abscess

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Surgical site infection (SSI)

• Risk factors age, malnutrition, obesity,
  immunocompromised, poor surg. tech, prolonged
  surgery, preop. shaving and type of surgery.
• Diagnosis
• Sup.SSI- erythema, oedema, discharge and pain
  
• Deep infections- no local signs, fever, pain,
  hypotension. need
  investigations.
• Treatment surgical / radiological intervention.

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Surgical site infection (SSI)

• Intra-abdominal infections
• Generalized
• Localized
• Prevention- good tech., avoid bowel injury, good
  anastomosis.
• Diagnosis- History, exam., investigations CT
  scan.
• Treatment- surgery/ intervention
• Antibiotics (aerobe
  anaerobe)

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UTI

• UTI are usually consequences of foley cathetar.
• The most common symptoms of a bladder infection
  are burning with urination (dysuria), frequency
  of urination and an urge to urinate.
• may also present with flank pain and a fever.

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UTI

• Diagnostic test
• -urinalysis (nitrate, estrase)
• -culture
• -urine microscopy (WBCgt10)
• The common org. is
• - E. coli, klebsiella, enterococcus
  staph. aureus

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TREATMENT

• Ab.with gram (-) spectrum
• -sulphamethoxasole
• -trimethoprim
• -gentamycin
• -ceprofloxacin
• Check culture sensitivity

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pneumonia

• Rout of infection
• -gross aspiration during anesthesia
• or intubation. Pathogen includes
• anaerobic organism gram(-)
• bacilli.
• - Atelectasis the collapsed lung may become
  secondarily infected
• -contiguous spread from another site.

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pneumonia

• Sing symptoms
• People with pneumonia often have one or more of
  these symptoms Fever, productive cough,
  shortness of breath, hypoxia and chest pain.
• Chest x-ray sputum culture are important to
  confirm the diagnose.

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treatment

• Hospital acquired pneumonia generally treated by
  cefuroxime, ceftriaxone for the usual pathogen(
  gram(-), s.aureus , strept.pn, H. influenzae)
  treatment of other pathogen.
• if there is recent Hx of abd.surg the infectious
  org. is anaerobes we should add clindamycin

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• If the pt. is comatose or has head trauma, DM, or
  renal failure the org. usually is s.aureus
  there is risk of MRSA we add vancomycin
• If the pt. take high dose of glucocorticoides the
  org. usually is legionella we add
  macrolide (azithromycin)

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• If the pt. has malnutrition, structural lung
  disease, glucocorticoid therapy the org. usually
  is pseudomonas.a
• Also if the pt. has Hx of neuro.surg. ,head
  trauma, ARDS, aspiration the org. usually is
  acinetobacter spp.
• All of them treated by the standard treatment
  aminoglycoside or ciprofloxacin IV
  antipseudomonal penicillin or imipenem.

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Sterilization and Disinfection

• Sterilization means ERADICATING all
  microorganisms and SPORES.
• Disinfection means the eradication of vegetative
  form only leaving SPORES.
• For sterilization, autoclave is the most common
  instrument used.
• Antiseptic is used on the surface of the body
  like alcohol, chlorohexidine
• Disinfectent is applied on metals and other
  instruments like formaldehyde formalin
• Plastic materials are best sterilized using
  chemicals while metalic instrument can be safely
  sterilized in the autoclave.

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antibiotics

• Chemotherapeutic agents that act on organisms
• Bacteriocidal Penicillin,Cephalosporin,
  Vancomycin, Aminoglycosides
• Bacteriostatic Erythromycin,Clindamycin,Tetracycl
  ine

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COMMON ANTIBIOTICS

• Penicillins- penicillin G
• Cephalosporins (II, III)-Cefruoxime, Ceftriaxone
• Aminoglycosides- Gentamycin
• Fluoroquinolones- Ciprofloxacin
• Glycopeptides- Vancomycin
• Macrolides- Erythromycin,
• Tetracyclines-, Doxycycline

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Prophylactic ab.

• Prophylaxis in clean-contaminated or high risk
  clean wounds.
• Antibiotic is given just before patient sent for
  surgery.
• Duration of antibiotic is controversial (one
  dose-or more , should not be used more than 24
  hour regimen )

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Wound Classification
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• Thank u