INFECTION IN SURGERY
host that does not usually give rise to disease at these respective
Organisms of importance to
the general surgeon
Rose Cooper
David John Leaper
An understanding of microbiology is fundamental for surgeons in
relation to surgical-site infections and perioperative care. Know-
ledge of the pathophysiological responses to important organisms
(together with advances in treatment and supportive intensive
care) enables surgeons to prevent and effectively control infectious
complications. There has been a rise in the incidence of health care-
associated infection because surgical interventions have become
more complex, with success in an increasingly elderly population
(particularly in orthopaedic and cardiovascular surgery). This
includes surgical-site infection, prosthetic infection, urinary tract
infection, respiratory tract infection (including ventilator-associ-
ated pneumonia; and bacteraemias which, if caused by methicil-
lin-resistant Staphylococcus aureus (MRSA), are used as an audit
tool for effective handwashing and hospital cleanliness).
Broadening the surgeon’s knowledge of organisms of impor-
tance to surgical practice is essential in order to keep pace with
advances in perioperative care. Also, patients presenting as sur-
gical emergencies (e.g. those presenting with diarrhoea and/or
abdominal pain) require segregation into those needing surgery
(e.g. perforated sigmoid diverticulitis) and those who can be treated
conservatively. A joint approach with a medical team is sensible
(e.g. with a gastroenterological team for ulcerative colitis or if there
is an underlying occult condition (e.g. a Richter femoral hernia)
presenting with diarrhoea for which surgery is mandatory).
This review discusses the role of micro-organisms in
perioperative infections (excluding infections due to viruses, prions
and burns) that are pertinent to surgeons.
Flora
The healthy body supports large numbers of indigenous organisms
that are termed ‘normal’ flora; they grow on the surface layers of
the body (e.g. skin, hair, nails) and they colonize mucous mem-
branes that line the upper respiratory system, gastrointestinal tract
and reproductive system. Skin and mucous membranes provide
mechanical barriers to microbial invasion, but colonizing com-
munities of microbial species are adapted for survival in these
locations, so residents coexist in a balanced relationship with the
Rose Cooper is a Principal Lecturer in Microbiology at the Centre for
Biomedical Sciences, School of Applied Sciences, University of Wales
Institute, Cardiff, UK.
David John Leaper is an Emeritus Professor of Surgery at Newcastle upon
Tyne University, Newcastle, and a Visiting Professor at Cardiff University,
Cardiff, UK.
SURGERY 23:8
sites. Additionally, the body constantly encounters new microbial
cells from other humans, animals or the environment. Defence
mechanisms prevent their ingress into deep tissues, so new arrivals
fail to survive or become part of the normal flora. Normal flora are
stable and predictable despite these changes (Figure 1).
Nevertheless, complex interactions exist between human and
microbial cells; some micro-organisms use specialized mechanisms
to evade defence mechanisms and achieve invasion, infection,
disease and damage. Such outcomes reflect fluctuations in the
susceptibility (immunocompetence) of the host, the virulence of
microbial species and their numbers. Hence, immunocompromised
individuals may be susceptible to infection by pathogens with rela-
tively low virulence, whereas immunocompetent individuals are
not. Similarly, organisms that are not regarded as overt pathogens
can take advantage of inappropriate host defences if they gain
unexpected acquisition to body sites (e.g. during surgery).
Surgeons are confronted by patients presenting with a wide
range of infections that have resulted from disturbances in
mechanical barriers as a result of trauma, surgery or disease.
Infections of skin and soft tissue
Minor skin infections: surgery is rarely indicated for small boils
and carbuncles, although lymphangitis, lymphadenitis and sys-
temic infection (bacteraemia, septicaemia) occasionally develop
and require antibiotic therapy. Human and animal bites often
introduce mixed cultures of bacteria into wounds that may develop
into abscesses. Occasionally, these and other minor infections
of skin and soft tissue present as large collections of pus (e.g.
in the breast or axilla) and simple surgical drainage is required.
Staphylococcus aureus is the principal organism causing suppu-
ration and recurrent abscesses can occur even if antibiotics are
used. Recurrence often relates to an underlying disease process
(e.g. hydradenitis suppurativa) which may involve anaerobes (e.g.
Bacteroides spp., coagulase-negative staphylococci, coliforms).
There may be an underlying systemic metabolic disease, which
must be excluded. Severe infections can also develop if bacteria
gain access to normally sterile parts of the body (e.g. from minor
traumatic events, during dental hygiene).
Leg, foot and pressure ulcers support mixed bacterial communi-
ties that can include large numbers of staphylococci, streptococci,
pseudomonads, coliforms and anaerobes. Treatment regimens
prioritize the amelioration of underlying conditions (e.g. ischae-
mia caused by vascular diseases, diabetes, friction and unrelieved
pressure). β-haemolytic streptococci, pseudomonads or other
pathogens must be eliminated (using topical antimicrobial agents
before surgery) if skin grafting or flap closure is considered. Sys-
temic antibiotics are reserved for evidence of invasive infection
and if a harmful pathogen (e.g. Streptococcus pyogenes) is present.
Changes in social and recreational activities (e.g. drug abuse, body
piercing, tattooing, exotic travel, sporting activities, AIDS) raise
the possibility of infected wounds with unexpected flora, so the
unusual pathogen must be considered if patients do not respond
to conventional therapy (Figure 2). An increase in the number of
immunosuppressed individuals and the homeless in the UK has led
to an increase in the incidence of tuberculosis (particularly with
multiple drug-resistant strains). Surgical drainage of mycobacterial
278 © 2005 The Medicine Publishing Company Ltd
 INFECTION IN SURGERY

Normal microbiota in humans

Bacteria Others
Gram-positive Gram-negative

Skin Corynebacteria Candida

Propionibacteria
Micrococci
Staphylococci
Enterococci
Upper respiratory tract Corynebacteria Neisseria Candida
Anaerobes spirochaetes Entamoeba gingivalis
Streptococci Mycoplasma
Staphylococci (nose)
Haemophilus

Gastrointestinal tract Clostridia Escherichia coli

Lactobacilli Klebsiella spp.
Enterococci Enterobacter
Anaerobes Proteus spp.
Bacteroides
Fusobacteria
Pseudomonas
Spirochaetes
Urogenital tract Lactobacilli Candida
Corynebacteria Mycoplasma
Staphylococci
Streptococci
1

abscesses (and also treatment of postoperative-exacerbated myco-
bacterial respiratory infections) presents a risk of cross-infection
to health care personnel.
Cellulitis: rapid spread of infection from localized cellulitis via
lymph nodes to the blood stream is life threatening. Generalized
erythema, increased oedema, bullae and lymphangitis are char-
acterstic symptoms; systemic signs of fever, rigors and confusion
suggest bacteraemia and septicaemia. Successful management
of cellulitis relies on early diagnosis and antibiotic administra-
tion; surgical intervention is not usually required. Common
causative agents are Streptococcus pyogenes, Staphylococcus aureus,
Pseudomonas aeruginosa; Gram-negative enteric bacteria are less
commonly associated with cellulitis.
Necrotizing fasciitis is a rare, life-threatening infection that
presents challenges to diagnosis and treatment because early
recognition is difficult. Synonyms include Fournier’s gangrene,
Meleney’s synergistic gangrene, phagedena gangrenosum, and
haemolytic streptococcal gangrene. The lower limbs are the most
commonly affected, with patients exhibiting exquisite pain, swell-
ing and fever on hospital admission. Tenderness, erythema and
warm skin are the early signs; small bullae develop as the infection
progresses and bullae with serous fluid are characteristic. Late signs
are large haemorrhagic bullae, necrosis, fluctuance and crepitus
(gas in the tissues is not exclusive to clostridial gas gangrene).
Minimal signs of cutaneous infection are present initially, but
extensive destruction of subcutaneous tissue with bacteraemia,
septic shock, multiple-organ failure and death may soon follow.
Bacterial toxins and surface superantigens cause recruitment of T-
cells to the infected tissue, which in turn secrete proinflammatory
cytokines that activate effector cells to elicit systemic inflammation
and massive tissue damage. This rapidly progressing infection may
follow minor skin trauma, surgery or ulcers.
Necrotizing fasciitis must be distinguished from cellulitis and
abscesses, and a clue is provided by systemic deterioration and
increased toxicity despite administration (i.v.) of broad-spectrum
antibiotics. MRI and frozen-section biopsy may aid early diagnosis,
but are not routinely available out of hours. Rapid diagnosis and
urgent, wide surgical debridement is essential.
Microbial culture discriminates between type-I infections where
mixed cultures of streptococci, staphylocooci, enterococci, entero-
bacteria and anaerobes are cultured; the causative agent is usually
Streptococcus pyogenes alone in type-II infections. Staphylococcus
aureus is rarely responsible for necrotizing fasciitis, but a sudden
increase in community-acquired MRSA has been reported in the
UK.
Gangrene: occasionally, streptococcal cellulitis progresses to necro-
tizing fasciitis, but more frequently gangrene is caused by anaer-
obes or mixed cultures that include anaerobes. Strict anaerobes
(e.g. Clostridium spp., Bacteroides, peptostreptococci) produce a
cocktail of destructive extracellular enzymes that allow invasion
into deep tissues with concomitant damage. Metabolic products
include malodorous organic amines and volatile fatty acids that
characterize their infections. Other facultatively anaerobic bacteria

SURGERY 23:8 279 © 2005 The Medicine Publishing Company Ltd

 INFECTION IN SURGERY

Infectious agents commonly encountered by general surgeons

Common pathogens Exceptional pathogens

Infections of skin Minor infections of skin
and soft tissue
Leg, foot and pressure ulcers
Cellulitis
Necrotizing fasciitis
Gangrene
Surgical-site infections
Intra-abdominal
infections
Staphylococci, streptococci, coliforms, Acinetobacter, Actinobacillus, Aeromonas
Pseudomonas, Bacteroides hydrophila, Capnocytophaga, Pasteurella
multocida, Stenotrophomonas maltophilia
Staphylococci, streptococci, Candida, Aspergillus, Fusarium,
coliforms, pseudomonads dermatophytes, mycobacteria
Staphylococci, streptococci, Haemophilus influenzae, coliforms,
Pseudomonas aeruginosa, Erysipelothrix
anaerobes
Streptococcus pyogenes, anaerobes +
coliforms, Staphylococcus aureus
Clostridium perfringens, clostridia,
anaerobes + coliforms
Staphylococci, streptococci, coliforms, Acinetobacter, Aspergillus, Candida,
Pseudomonas, anaerobes Citrobacter, coagulase-negative
staphylococci, Mycoplasma, Serratia spp.
Campylobacter jejuni Clostridium difficile
Escherichia coli 0157 Cryptosporidium
Salmonella spp.
Shigella spp.
Noroviruses
Yersinia entercolitica
Anaerobes

derived from the gut (Escherichia coli, Enterobacter, Klebsiella,

Enterococcus, streptococci) form synergistic relationships with
obligate anaerobes that reduce the number of anaerobes required
to establish infection. The most common cause of gas gangrene
is Clostridium perfringens, but other clostridia may be isolated.
The trauma leading to tissue contamination is often trivial or
forgotten. Endospores of these bacteria are widely distributed in
soil and water that has been contaminated by animal and human
faeces, although acquisition from air, dust and soiled clothing is
also possible. Clostridial gas gangrene is more commonly seen in
military practice after high-velocity injuries that cause ischaemia
and cavitation with gross contamination by foreign material (e.g.
clothing, soil).
Whereas cellulitis is usually confined to superficial layers and
necrotizing fasciitis involves deeper tissue (e.g. fascial planes),
gangrene has the potential for extensive migration. The speed of
progress varies between indolent and rapid, according to immune
status and the virulence of the causative agents. Clinical signs and
symptoms vary, but radical debridement of necrotic and infected
tissue (together with constant monitoring and organ support on
ITU/HDU) is important; repeat surgery may be required. Dis-
crimination between necrotizing fasciitis and gangrene is essential
because antibiotic treatment regimens differ: high-dose benzyl
penicillin for streptococci and metronidazole for anaerobes. Empiri-
cal combination therapy for both is essential before microbiological
tests allow a differential diagnosis.
Intra-abdominal infections
Several organisms (e.g. Yersinia) cause abdominal pain that may
mimic appendicitis and hence present as a surgical emergency.
History-taking may elicit gynaecological symptoms (with the
correct treatment for a Chlamydia infection and avoidance of
surgery) or an association between an infected meal, abdominal
pain with fresh rectal bleeding and a Campylobacter infection.
A patient who has recently been abroad and who presents as a
surgical emergency (particularly if signs and symptoms are not
typical of a ‘surgical abdomen’) should be assessed by a specialist
in infectious diseases.
Knowledge of the bacteria involved in general peritonitis is
important because it dictates which empirical antibiotic regimen
is appropriate, with or without surgery. In the gastrointestinal
tract, the predominant organisms linked to disease are aerobic
Gram-negative bacteria and anaerobes act synergistically with
an inflammatory process (e.g. colonic diverticulitis), perforation
(e.g. appendicitis) or ischaemia (e.g. small-bowel infarct). There
are exceptions: the peritoneum after a perforated duodenal ulcer
initially remains sterile, but soon becomes contaminated; biliary
peritonitis after a bile leak may be contaminated only with enteric
bacteria. Empirical antibiotic treatment is usually recommended
for all cases of generalized peritonitis, and aims to cover aerobic
Gram-negative bacteria and Bacteroides using a broad-spectrum
combination with metronidazole. Local hospital guidelines should

SURGERY 23:8 280 © 2005 The Medicine Publishing Company Ltd

 INFECTION IN SURGERY
be consulted, but the use of second-line antibiotic therapy with e.g.
carbapenems or new antibiotic combinations should be reserved
for severe pancreatitis or anastomotic leak.
Postoperative infections
The incidence of health care-associated infection continues to
increase and is a huge financial burden for the UK NHS. Most
(surgical-site infections, urinary and respiratory infections,
bacteraemia) occur postoperatively, contributing significantly to
morbidity, prolonged stay in hopsital, increased treatment costs,
and mortality (see ‘Sources of surgical infection’, page 284).
Surgical-site infection is the third most common health care-asso-
ciated infection in the UK and is preventable. Infections associated
with surgical incisions have been recognized and risk factors
identified. A classification of wounds based on the extent of their
microbial contamination was established in 1964 (see ‘Asepsis,
antisepsis and skin preparation’, page 297) and definitions of
infection were formulated by the US Center for Disease Control in
1988 and modified in 1992 (Figure 3). Classification discriminates
between superficial, deep incisional and organ/space infections.
The identification of surgical-site infection is largely characterized
by the appearance of the cardinal signs of Celsus (calor; rubor,
redness or erythema; dolor, pain; and tumour-swelling or oedema),
together with pus and, in severe cases, signs of systemic inflam-
mation. However, more subtle definitions are available and scoring
systems have been developed.
Bacteria are usually associated with surgical-site infections, but
Candida may be isolated (rare). Staphylococcus aureus is the most
common isolate, even after colonic surgery, although enterococci
and coagulase-negative staphylococci are also commonly isolated.
The increased prevalence of antibiotic-resistant strains makes
empirical antibiotic therapy less reliable, and antibiotic sensitivity
testing essential. Hospital- and community-acquired rates of MRSA
infection are increasing in the UK, and methicillin resistance has
spread to coagulase-negative staphylococci. Intermediate- and
high-level resistance of Stapylococcus aureus to vancomycin has
been reported. Surgical-site infections can also be caused by
enteric bacteria (e.g. Escherichia coli, Proteus mirabilis, Klebsiella
pneumoniae, Citrobacter, Serratia marcescens), in synergy with
anaerobes, particularly after colorectal surgery. Gram-negative
bacteria (Pseudomonas aeruginosa, Acinetobacter spp.) can infect
surgical-site infections opportunistically; Bacteroides spp. (and
occasionally Fusobacterium) are typical anaerobic isolates.
Postoperative diarrhoea
Patients with diarrhoea may present as surgical emergencies,
within a few days after admission or even postoperatively. Spe-
cific associations with abdominal pain are discussed above, but
infective causes of diarrhoea at admission must be differentiated
from inflammatory bowel disease (e.g. Crohn’s disease, ulcerative
colitis). Highly infectious diseases caused by e.g. Salmonella or
Shigella should be considered if several patients present with a
similar syndrome and arise from the same environment (e.g. nurs-
ing home, psychiatric ward). A history of several patients in one
ward bay presenting with profound vomiting and diarrhoea should
raise concern for Norovirus or Clostridium difficile enteritis (the
SURGERY 23:8
Types of incisional infections
Superficial Manifest within 30 days of surgery
Infection is localized to superficial tissue
At least one of the following criteria are observed:
purulent discharge
pathogens cultured from affected tissue or
wound exudate
signs and symptoms of infection (pain, swelling,
erythema, fever) recorded
diagnosis of infection by the surgical team
Deep Manifest within 30 days of surgery if an implant
is not present or
up to one year with an implant
Infection involves deep tissue and is associated
with surgery
At least one of the following criteria are observed:
purulent discharge
spontaneous dehiscence of a deep incision
or one deliberately opened when the patient
exhibits fever (>38oC) and pain
abscess or other evidence of infection on
inspection
diagnosis of infection by the surgical team
Organ/space Manifest within 30 days of surgery if an implant
is not present or
up to one year with an implant
Infection appears to be related to surgery and
affects the part of the anatomy opened during
surgery (but not the incision)
At least one of the following criteria are observed:
purulent drainage from a drain inserted into the
organ/space
pathogens cultured from affected tissue or fluid
abscess or other evidence of infection on
inspection
diagnosis of infection by surgical team
3
latter can present as a surgical emergency). The accompanying
abdominal pain and bleeding per rectum should prompt investiga-
tion for formation of adherent pseudomembrane with extensive
mucosal inflammation without tissue invasion. Another clue is the
previous use of antibiotics, particularly clindamycin or extended-
spectrum cephaloporins. Clostridium difficile diarrhoea is caused
by the production of toxin-A (an enterotoxin), and diagnosis
depends on toxin detection in diarrhoeal stools at an early stage.
A neutralized cell cytotoxicity assay and an immunoassay that
characterizes toxin-A and toxin-B (a cytolytic toxin) should be per-
formed. Outbreaks within a unit should prompt molecular typing
of isolates to investigate the possibility of inter-patient transfer.
Appropriate treatment and isolation can be given (in collabora-
tion with an infectious diseases specialist) after the diagnosis is
made. 
281 © 2005 The Medicine Publishing Company Ltd