SURGICAL INFECTIONS

Facebook: Happy Friday Knight

Basic Science Topic for Residents
Department of Surgery
Thailand
 Topics
• Pathogenesis of Infection
• Microbiology of Infectious agents: bacteria, fungi,
viruses
• Prevention and Treatment of Surgical Infections
• Infections of Significance in Surgical Patients
– SSI
– IAI
– SSTI
– post-operative nosocomial infection: CAUTI, HAP, CRBSI
– Sepsis
PATHOGENESIS OF INFECTION
 Host Defenses

http://textbookofbacteriology.net/innate_2.html
 Host Defenses
• Skin
– Most extensive physical barrier
– Normal flora: gram-positive aerobes =>
Staphylococcus, Streptococcus, Corynebacterium,
Propionibacterium.
– Infraumbilicus flora: gram-positive plus Enterococcus
faecalis and faecium, Escherichia coli, other
enterobacteriaceae, and Candida albicans
– Skin infections (eczema, dermatitis) are associated
with overgrowth of skin flora
 Host Defenses
• Respiratory Tract
– Possesses several host defenses to keep distal
bronchi and alveoli sterile
– Mucus traps large particles including microbes 
mucus passes into upper airway by ciliated
epithelium  cough  small particles at lower
tract were cleared by pulmonary alveolar
macrophages
 Host Defenses
• In healthy individuals, the urogenital, biliary,
pancreatic ductal, and distal respiratory tracts
do not possess resident microflora
• But may be present if the barriers are affected
by
– Disease: malignancy, inflammation, calculi,
foreign body
– External source: foley, aspiration
 Host Defenses: GI tract

• Stomach
– Highly acidic
– Populations: 102 – 103 CFU/ml
– Acidity depends on drugs and disease
• Small bowel
– Populations: 105 – 108 CFU/ml in terminal ileum
 Host Defenses: GI tract
• Colon
– Low oxygen: most extensive host microflora
– Anaerobe: aerobe = 100:1
– 1011 – 1012 CFU/ml in feces
– Anaerobes: Bacteroides fragilis, Clostridium,
Bifidobacterium, Eubacterium, Fusobacterium,
Lactobacillus, Peptostreptococcus
– Aerobes: Escherichia coli and other
enterobacteriaceae, Enterococcus faecalis and faecium
– Fungus: candida
– Salmonella, Shigella, Vibrio still cause problems
 Host Defenses

• Outcome factors:
– Initial number of microbes
– The rate of microbial proliferation
– Microbial virulence
– Potency of host defenses
 Definitions
• Interaction between microbe and resident
– Eradication
– Containment: abscess
– Logoregional infection: cellulitis
– Systemic infection: bacteremia
 Definitions
• Infection = presence of microbes in host tissue
or bloodstream
• SIRS = systemic manifestation
• Sepsis = SIRS + infection
• Severe sepsis = sepsis + new-onset of organ
failure
• Sepsis-induced tissue hypoperfusion =
infection-induced hypotension, elevated
lactate, or oliguria
 Definitions: Septic Shock
• Septic shock = sepsis + circulatory failure
(from persistent hypotension (SBP<90 mmHg)
despite of adequate fluid resuscitation
• 40% of patients with severe sepsis
• Mortality rate 30-66%
 Definition: SIRS

• Systemic Inflammatory Response Syndrome:

– Body temperature: > 38oC, <36oC
– HR: > 90/min
– Tachypnea: RR > 20/min, PaCO2 < 32 mmHg
– WBC: >12000 /mcL, < 4000, band form > 10%
 CRP
Procalcitonin
Lactate

Dellinger RP et al. “Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis
and Septic Shock: 2012”. Critical Care Medicine. Volume 41 number 2, (February 2013): page 585
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill
Education, 2015. page 139
 Definitions: PIRO

• Predisposing conditions: age, CKD, cancer

liver disease
• Infection: positive H/C
• Response of the host: CRP, WBC, HR
• Organ dysfunction: lactate
 MICROBIOLOGY
OF
INFECTIOUS AGENTS
 Bacteria
• Majority of surgical infection
• Gram +ve:
– SSI: aerobic skin commensals (Staphylococcus
aureus and epidermidis, Streptococcus pyogenes)
– Nosocomial infection: Enterococcus faecalis and
faecium
Staphylococcus aureus Streptococcus pyogenes

www.microbeworld.org http://www.snipview.com/q/Streptococcus_pyogenes
 Pathogenesis of Streptococcus pyogenes infections
http://textbookofbacteriology.net/streptococcus_2.html
Adapted from Baron's Medical Microbiology Chapter 13, Streptococcus by Maria Jevitz Patterson.
 Bacteria
• Gram –ve:
– Enterobacteriaceae: Escherichia coli, Klebiella
pneumoniae, Serratia marcescens, Enterobacter,
Citrobacter, Acinetobacter
– Others: Pseudomonas aeruginosa, Aeromonas

• Anaerobes:
– Colon: Bacteroides fragilis
– Skin: Propionibacterium acnes
 Fungi
• Lab: KOH, India ink, Giemsa
– Look for branching and septation
• Polymicrobial infection/fungemia: Candida
albicans
• Aggressive soft tissue infection: Mucor,
Rhizopus, Absidia
• Opportunistic infections: Aspergillus,
Blastomyces, Cryptococcus
 Mucormycosis
Candida albicans http://medlibes.com/entry/mucormycosis
https://en.wikipedia.org/wiki/Candida_albicans

Aspergillus Cryptococcus neoformans

https://www.emlab.com/s/sampling/env-report-09-2006.html https://en.wikipedia.org/wiki/Candida_albicans
 Viruses
• Blood-borne pathogens: HBV, HCV, HIV
– Occupational infection rate (Needle stick injury) =
30:3:0.3  100:10:1

• Immunocompromised host due to

transplantation: adenovirus, EBV, CMV, VZV,
HSV
PREVENTION AND TREATMENT
OF
SURGICAL INFECTIONS
Townsend CM et al. Sabiston Textbook of Surgery: The
Biological Basis of Modern Surgical Practice. 19th ed.
Philadelphia: Elsevier Saunders, 2012. page 246
 Razor VS clippers
http://www.medscape.org/viewarticle/557689_5
 Source Control
• I&D
• Debridement
• Remove foreign body
• Bowel closure or resection and abdominal
toilet for GI perforation
• Amputation
 Antibiotic Use
• Prophylaxis: administration of antibiotic (s) to
reduce the number of microbes in specific
procedures
– Limited to time prior to and during the procedure
• Empiric Therapy: use of antiobiotics in high risk
of surgical infection
– Short course: 3- 5 days
– Discontinue based on:
• Biological data (negative culture)
• Clinical improvement
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 146
 Antibiotic Use
• Empiric Therapy in term of established
infection: monomicrobial VS polymicrobial
– Monomicrobial: frequently are nosocomial
infection postoperatively (UTI, pneumonia,
bacteremia)
– Broad spectrum first, then narrowing based on
response and culture results
– F/U culture is advised
– Polymicrobial: source control + antibiotics
 Antibiotic Use: Duration
In case of monomicrobial infections:
• UTI: 3 -5 days
• Pneumonia: 7 – 10 days
• Bacteremia: 7 – 14 days
– Too long will increase risk of superinfection by
resisted organism
 Antibiotic Use: Duration
• Extend the course to 6 – 12 weeks in case of
– Osteomyelitis
– Endocarditis
– Prothetic infection which it is hazardous to
remove: hip and knee
 Antibiotic Use: Duration
• Penetrating GI trauma with absence of
extensive contamination: 12 – 24 hrs
• Gangrenous to ruptured appendicitis: 3 – 5
days
• Perforated viscus with moderate degree
contamination: 5 – 7 days
• Feculent peritonitis (extensive contamination:
7 – 14 days
 Antibiotic Use
• Misuse:
– Superinfection by resisted organism
– Clostidium difficile colitis
– expensive

• Allergy: Don’t forget!!!

– Penicillin allergy cross-reactivity:
• 1% for carbapenems
• 5 – 7% for cephalosporin
INFECTIONS OF SIGNIFICANCE
IN SURGICAL PATIENTS
• Surgical Site Infections (SSI)
• Intraabdominal Infection: peritonitis and organ
infections
• Skin and Soft Tissue Infections
• post-operative nosocomial infections: CAUTI,
CRBSI (CLA-BSI), HAP
• sepsis
 Surgical Site Infections
• Related to 3 factors
1. The degree of contamination
2. Duration of procedure
3. Host factors: malnutrition, DM, obesity,
immunocompromised status
Brunicardi FC et al. Schwartz’s Principles of Surgery.
10th ed. McGraw-Hill Education, 2015. page 147
 Surgical Site Infections

• Classification
– Incisional:
• Superficial
• Deep
– Organ/space

Mangram AJ et al. “Guideline for Prevention of Surgical Site Infection, 1999”. Infection Control and Hospital
Epidemiology. Vol. 20 No.4, (January 1999): page 251
 Surgical Site Infections: Criteria
Within 30 days post-op or a year with prosthesis plus:
Criteria Superficial Deep Organ/space
Purulent d/c / / /
c/s positive / - /
Signs & symptoms Pain, tenderness, Dehiscent, fever, -
localized swelling, pain, tenderness,
redness, heat, opened by surgeon
opened by surgeon
Evidence found by: - Direct exam, re-op, Direct exam, re-op,
histopathology, histopathology,
Xray Xray
Diagnosis by / / /
surgeon or attending
physician
 Surgical Site Infections: Surgical Wound

• Clean (class I and I D)

• Clean/contaminated (class II)
• Contaminated (class III)
• Dirty (class IV)
 Surgical Site Infections: Surgical Wound

• Clean wound:
– No infection present
– Only skin microflora contaminate the wound
– Not enter hollow viscus: RS/GI/GU
• I D: clean wound with prosthetic devices
• Examples: hernia repair, breast biopsy
• Expected infection rates: 1 – 2%
 Surgical Site Infections: Surgical Wound

• Clean/contaminated wound: classifies into

elective RS/GI/GU and colorectal surgery
– Open under controlled circumstances without
gross spillage of content
– Expected infection rate: both groups are different
• Non-colorectal: 2.1 – 9.5%
• Colorectal: 4 – 14%
 Surgical Site Infections: Surgical Wound

• Contaminated wound:
– Open accidental wound encountered early after injury
– Gross spilage of viscus contents such as from the
intestine
– Incision through inflamed tissue
• Examples: appendectomy trough focal type
appendicitis, penetrating abdominal trauma, large
tissue injury, enterotomy during bowel
obstruction
• Expected infection rate: 3.4 – 13.2%
 Surgical Site Infections: Surgical Wound

• Dirty wound:
– Traumatic wound that delayed treatment result in
necrotic tissue or purulent material
– Hollow viscus organ perforation
• Examples: NF, ruptured appendicitis and
diverticulitis
• Expected infection rate: 3.1 – 12.8%
 Intra-Abdominal Infections
• Could be in intraperitoneal cavity,
retroperitoneal space, or intra-abdominal
vicera
• Peritoneal cavity:
– Lined by serous membrane
– Contain fluid to moist space
– Non-inflamed serous fluid is clear, low specific
gravity (<1.016), low protein ( <3g/d), albumin
predominates, WBC < 250/mm3 mainly
mononuclear
 Intra-Abdominal Infections: Classification

• Primary microbial peritonitis (Spontaneous Bacterial

Peritonitis: SBP): microbe invades peritoneal cavity
via hematogenous or distant source of infection

• Secondary microbial peritonitis: peritoneal infection

secondary to intra-abdominal lesion

• Tertiary (postoperative, persistent) peritonitis:

persistent or recurrent infection after operation
Intra-Abdominal Infections: Classification

• Primary peritonitis (SBP)

– microbe invades peritoneal cavity via
hematogenous or distant source of infection
– PMN ≥ 250/mm2 + 1 pathogen
– Common in patients with ascites or whom treated
by PD
– Organisms: E.coli, K.pneumoniae, pneumococci
– Treatment: antibiotics for 2 – 3 wks ± catheter
removal
Intra-Abdominal Infections: Classification

• Secondary peritonitis
– peritoneal infection secondary to intra-abdominal
lesion: perforation, appendicitis, diverticulitis
– PMN ≥ 250/mm2 + multiple pathogens
– Treatment:
• Source control by resect or repair lesion
• Antiobiotics cover both aerobes and anaerobes
– Most morbid form: colonic perforation
– Mortality rate: 5 -6% in controllable, 40% in
uncontrolled
Intra-Abdominal Infections: Classification

• Tertiary peritonitis
– persistent or recurrent infection after operation,
could be from abscess forming or anastomosis
leakage
– More common in immunosuppressed patients
– Organisms: Enterococcus faecalis and faecium,
Staphylococcus epidermidis, Candida albicans,
Pseudomonas aeruginosa – mixed
– Mortality rate more than 50%
Intra-Abdominal Infections: Tertiary Peritonitis

• Investigation: CT
• Treatment:
– Antibiotics for 3 -7 days
– Percutaneous drainage
– Surgical drainage in
• Multiple abscesses
• Abscess in proximity to vital structure
• Anastomosis leakage
Intra-Abdominal Infections: Tertiary Peritonitis

– Remove drain when:

• Clinically improved
• Abscess cavity collapse
• Output less than 10 – 20 ml/day
• No evidence of ongoing source of
contamination
Intra-Abdominal Infections: Ascites
• PMN ≥ 250/mm2 + 1 pathogen = Spontaneous
bacterial peritonitis or primary peritonitis

• PMN ≥ 250/mm2 + multiple pathogens =

secondary peritonitis

• PMN < 250/mm2 + multiple pathogens =

bowel perforation due to paracentesis
 Intra-Abdominal Infections
• Liver and splenic abscesses
– 80% pyogenic, 20% parasitic + fungal
– Causes: neglect appendicitis and diverticulitis
formerly, manipulation of the biliary tract, 50%
unknown
– Organisms: E.coli, K.pneumoniae, Bacteroides
fragillis
Intra-Abdominal Infections: Liver Abscess

• Treatments:
– Correction of underlying cause
– Antibiotics (gram negative + anaerobe) for 6-8
wks
– Percutaneous aspiration and c/s is useful for
antibiotics guide, but catheter placement is not
effective
– Surgical drainage may become necessary if fail
medication
– Necrotic hepatic malignancy must not be mistaken
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 1284
Intra-Abdominal Infections: Liver Abscess

• Amoebic liver abscess

– Entamoeba histolytica
– Characteristics:
• Most commonly located in superoanterior aspect of right
lobe near diaphragm
• necrotic central portion
• Anchovy paste
– Investigations: U/S, CT
– Treatment:
• Metronidazole for 7 – 10 days with imaging for F/U
• Aspiration rarely needed: reserved in patients with large
abscess, fail medication, suspected superinfection, and
abscess at left lobe
 Intra-Abdominal Infection
• Secondary pancreatic infection
– Examples: infected pancreatic necrosis, abscess
– Suspected in patients with
• Fail to resolve in 7 – 10 days (ongoing SIRS)
• Intially recover and develop sepsis 2 – 3 wks later
– Investigation: CT and CT-guided FNA
– Diagnosis:
• CT-guided FNA found positive Gram stain or culture
• CT: gas gangrene
 Normal Pancreas
http://www.pancreapedia.org/reviews/anatomy-and-histology-of-pancreas

Infected Pancreatic Necrosis

Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 152
Skin and Soft Tissue Infection
Abscess: a swollen area within body tissue, containing
an accumulation of pus
http://www.humanillnesses.com/original/A-As/Abscess.html
Folliculitis: inflammation of the hair follicles
http://www.aocd.org/?page=Folliculitis
Furuncles: infected hair follicles with fluctuation
http://health-pictures.com/infection/furuncle.htm#.VdTTZvmqqko
Carbuncle: multiple furuncles
http://byebyedoctor.com/carbuncle/
https://www.pinterest.com/pin/455637687272631453/
Erysipelas http://diseasespictures.com/erysipelas/
Cellulitis
http://billqualls.com/survival/cellulitis/index.html
http://billqualls.com/survival/cellulitis/index.html
http://billqualls.com/survival/cellulitis/index.html
Necrotizing Fasciitis
http://www.sailinglinks.com/vanuatu.htm
NF after debridement
http://www.sailinglinks.com/vanuatu.htm
With vacuum dressing
http://www.sailinglinks.com/vanuatu.htm
resolved
http://www.sailinglinks.com/vanuatu.htm
Necrotizing Soft Tissue Infection (Fasciitis: NF)

• Extremely high mortality rate (80-100%) if

delay treatment
• 16-24% in rapid recognition
• “gas gangrene, rapidly spreading cellulitis, and
necrotizing fasciitis”
• Risk factors:
– elderly
– Immunosuppressed including diabetes
– Peripheral vascular disease
 Necrotizing Soft Tissue Infection

• Highly suspected in sepsis with minimal wound

• History:
– within 1 -2 days
– Pain out of proportion
• Examination:
– Greyish, turbid semipurulent material (dishwater pus)
– Skin changes: bronze color or brawny induration
– Blebs (hemorrhagic)
– crepitus
 Dishwater pus
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 153
 Necrotizing Soft Tissue Infection

• Common organisms: mixed

– Streptococcus pyogenes
– Pseudomonas aeruginosa
– Clostridium perfringens
• Investigation:
– only lab
– imaging is not recommended due to delay
intervention
 Necrotizing Soft Tissue Infection

• Treatment:
– Emergent aggressive and radical debridement
– Direct visualization of potentially infected tissue
– Immediate IV antibiotics cover all gram-positive
and negative aerobes, and anaerobes
– Septic shock resuscitation
 Necrotizing Soft Tissue Infection: after debridement
Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015. page 153
 Postoperative Nosocomial Infection

• Catheter-Associated Urinary Tract Infection

(CAUTI)

• Hospital-Acquired Pneumonia (HAP)

• Catheter-Related Bloodstream infection

(CRBSI) or Central line-associated
bloodstream infection (CLA-BSIs)
Postoperative Nosocomial Infection: CAUTI

• Catheter-Associated Urinary Tract Infection

• UTI: consider based on UA
– +ve WBC
– +ve bacteria
– +ve leukocyte esterase
• Diagnose when urine C/S show number of
microbes:
– > 104 CFU/ml in symptomatic patients
– > 105 CFU/ml in asymptomatic ones
Postoperative Nosocomial Infection: CAUTI

• Treatment: single antibiotic for 3 – 5 days

against common organism (E.coli,
K.pneumoniae)
– Commonly use: ofloxacin (200) 1 tab po bid

• Prevention:
– Remove catheter as soon as possible, usually
within 1 -2 days and patients are mobile
Hospital- and Ventilator-Acquired Pneumonia

• Diagnosis:
– Purulent sputum
– Leukocytosis
– Fever
– New abnormal CXR findings
• The pathogens are usually multiple drug
resistance
• Prevention: wean ETT ASAP, early
tracheostomy
 Catheter-Related Bloodstream Infection

• Catheter-Related Bloodstream infection

(CRBSI) or Central line-associated
bloodstream infection (CLA-BSIs)
• Risk factors:
– Duration
– Insertion or manipulation under emergency or
nonsterile conditions
– Use of parenteral nutrition
– Multiple lumen catheter
 Catheter-Related Bloodstream Infection

• Treatment
– Remove catheter
– Antibiotics: Vancomycin against MRSA
– In low virulence such as S.epidermidis, if no other
vascular access  antibiotics for 2 – 3 wks
• Prevention
– Full sterile technique
– Remove catheter ASAP
Sepsis
http://www.nejm.org/doi/full
/10.1056/NEJMoa010307
 References

Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill

Education, 2015.

Townsend CM et al. Sabiston Textbook of Surgery: The Biological Basis of

Modern Surgical Practice. 19th ed. Philadelphia: Elsevier Saunders, 2012.

Mandell et al. Principles and Practice of Infectious Diseases. 7th ed.

Philadelphia: Churchill Livingstone, 2010.

Longo DL et al. Harrison’s Principle of Internal Medicine. 18th ed. McGraw-

Hill, 2012.

ทรงชัย สิมะโรชน์ และคณะ. “การติดเชื ้อทางศัลยกรรม (Surgical Infection)” ใน ศัลยศาสตร์ วิวฒ

ั น์ เล่ม
51. กรุงเทพฯ: สานักพิมพ์กรุงเทพเวชสาร, 2556.
 References
Dellinger RP et al. “Surviving Sepsis Campaign: International Guidelines for Management of
Severe Sepsis and Septic Shock: 2012”. Critical Care Medicine. Vol. 41 No. 2, (February 2013):
page 580-620

Gould CV et al. “Guideline for Prevention of Catheter-Related Urinary Tract Infection 2009”
CDC’s Healthcare Infection Control Practices Advisory Committee

Mangram AJ et al. “Guideline for Prevention of Surgical Site Infection, 1999”. Infection Control
and Hospital Epidemiology. Vol. 20 No.4, (January 1999): page 247-278

O’Grady NP et al. “Guidelines for Prevention of Intravascular Catheter-Related Infection, 2011”

CDC

Stevens DL et al. “Practice Guidelines for the Diagnosis and Management of Skin and soft tissue
infections: 2014 Update by in Infectious Disease Society of America”. Clinical Infectious
Diseases Advanced Access published June 18, 2014. Downloaded from
http://cid.oxfordjournals.org/ by guest
 References
Tenner S et al. “American College of Gastroenterology Guideline: Management of Acute
Pancreatitis, 2013”. American Journal of Gastroenterology. Online journal, (July 2013).

http://www.cdc.gov/HAI/infectionTypes.html