SURGICAL INFECTIONS

• Presenters: MOSES GRACE KINTU

ALI BAGUMA

• Tutor : MR KIMULI

• Date : 12th May 2017

• Time : 8:00 -9:00 am

• Venue : ALT
 Outline

• History
• Definition
• Classification
• Risk factors
• Presentation
• Diagnosis
• Pathogens
• Specific antibiotics
• Specific surgical infections
• Management
 History

• 1846: Morton introduces anaesthesia-little advances in operations

• Early 20th Century: Ignaz Phillip Semmelweis’ work
• Joseph Lister’s introduction of antisepsis into practice of
medicine
• Reduced infection rates and mortality in surgical patients
• Middle of 20th century: antibiotic therapy
 Definitions
• Surgical infections: are those that occur following a surgical procedure or
those that require surgical intervention as part of their management.
• They are terized by breech in the anatomic/mechanical defense mechanisms
(barriers).
Any infection that follows surgery can be termed primary or secondary
• Primary: present in or on the host thus acquired endogenously
• Secondary: acquired from a source outside the body-exogenous
 Classification of surgical infections

• Infection that follows surgery or admission to hospital is termed-

health care associated infection (HAI) There are 4 main groups:-
1. Respiratory infections (including ventilator associated pneumonia)
2. Urinary tract infections ( related to urinary catheters )
3. Bacteremia
4. Surgical site infections
Protective mechanisms.
1.Epithelial surfaces act as mechanical barrier
2. phagocytes, antibodies complements
3. macrophages, leukocytes, opsonins

Risk factors for surgical infections

1. Malnutrition
2. diabetes mellitus
3. obesity
4. uraemia
5. Jaundice
6. malignancy, immunosuppression
7. radiotherapy, chemotherapy
8. HIV
9. foreign body, Ischaemia, haematoma
 Surgical site infections

• Surgical site infections (SSI) are those present in any location along
the surgical tract after a surgical procedure
• Term changed by the Surgical wound infection task force in 1992
• Unlike surgical wound infections, SSIs involve postoperative infections
occurring at any level (incisional or deep ) of a specific procedure
• Can occur anytime from 0 to 30 days post operative or up to 1 year
• After a procedure involving implantation of a foreign material
 Classification of SSIs
SSIs are divided into Three :-
1. Incisional superficial (skin, subcutaneous tissue)
2. Incisional deep ( fascial plane and muscles )
3. Organ/ space related ( anatomic location of procedure itself)

Can also be grouped as

 Major SSIs; a wound that either discharges significant quantities of pus or
needs a secondary procedure to drain it.
(systemic illness, delayed return home)
 Minor SSIs; may discharge pus or infected serous fluid (no excessive
discomfort, systemic sign or delayed return home)
 Surgical wound classification

According to degree of contamination

1. Clean : an uninfected operative wound in which no inflammation is
encountered and resp, alimentary, genital or infected urinary tract is not
entered
2. Clean-contaminated : an operative wound in which the respiratory,
alimentary, genital or urinary tract is entered under controlled conditions
3. Contaminated : open, fresh, accidental wounds. Operations with major
breaks in sterile technique or gross spillage from GIT
4. Dirty : old traumatic wounds with retained devitalized tissue and
those that involve existing clinical infection or perforated viscera
 Epidemiology

• SSIs are the most common nosocomial infection

• Constitute 38% of all infections in surgical patients
• Incisional infections are the most common
• Account for 60% to 80% of all SSIs
• Organ/space related SSIs account for 93% of SSI related mortalities
 Causes and risk factors for SSIs

Can be compiled within one of these major determinants :

• Bacterial factors, local wound factors and patient factors
Micro-organism
 Remote site infection
 Long-term care facility
 Recent hospitalization
 Duration of procedure
 Wound class
 ICU patient
 Previous antibiotic therapy
 Preoperative shaving
 Bacterial no., virulence and antimicrobial resistance
 Causes and risk factors for SSIs

• Local wound factors

Surgical technique
 Hematoma/ seroma
 Necrosis
 Sutures
 Drains
 Foreign bodies
 Causes and risk factors for SSIs

• Patient factors
 Age
 Immunosuppression
 Steroids
 Malignancy
 Diabetes
 Malnutrition ( obesity, weight loss )
 Multiple co-morbid conditions
 Perioperative transfusions
 Cigarette smoking
 Oxygen
 Temperature
 Glucose control
 Prevention of SSIs

3 milestones in preventing SSIs have been defined

1. Aseptic and antiseptic technique introduced by Lister
2. Proper use of prophylactic antibiotics
3. Practices that optimize and maximize the patient’s own
ability to prevent infection
• Preventive measures can also be classified according to
the 3 determinants of wound infection and timing at which
measures are implemented ( preoperative, intraoperative and
postoperative )
 Preoperative prevention measures

• Microorganism
 Shorten preoperative stay
 Antiseptic shower preoperatively
 Appropriate preoperative hair removal or no hair removal
 Avoid or treat remote site infections
 Antimicrobial prophylaxis
• Local
 Appropriate preoperative hair removal or no hair removal
 Preoperative prevention measures

• Patient
 Optimize nutrition
 Preoperative warming
 Tight glucose control (insulin drip)
 Stop smoking
 Intraoperative prevention measures

• Microorganism
 Asepsis and antisepsis
 Avoid spillage in GI cases
• Local
Good Surgical technique
 Prevention of hematoma/seroma
 Good perfusion
 Complete debridement
 Smaller potential dead spaces
 Monofilament suture use
 Justified drain use ( closed )
 Limit use of sutures/foreign bodies
Delayed primary closure
 Intraoperative prevention measures

• Patient
 Supplemental oxygen
 Intraoperative warming
 Adequate fluid resuscitation
 Tight glucose control ( insulin drip )
 Postoperative prevention measures

• Microorganism
 Protect incision for 48-72 hours
 Remove drains as soon as possible
 Avoid postoperative bacteremia
• Local
 Postoperative dressing for 48-72 hours
• Patient
 Early enteral nutrition
 Supplemental oxygen
 Tight glucose control ( insulin drip )
 Surveillance programs
 Presentation

• Infection in early post op period (<48hrs) are most likely to be

respiratory or urinary; wound infection come later
• Implant related infections may present weeks, months or even years
• Leakage of a GI anastomosis usually presents after 5-6 days
with- low grade pyrexia, abdominal signs & symptoms,
leakage of bowel content from surgical drains
• Cough, dysuria, abdominal pain
• Tachycardia, tachypnea, pyrexia
• Hypotension and other signs of shock
• Drainage of pus at surgical site
 Diagnosis

• Whenever possible, identify focus of infection

• Can be done by; plain X-ray, ultrasound, CT or MRI
• Then take cultures (urine, sputum, pus swabs) before ABCs
Screening for sepsis
Any of the two present
• Temperature <36 or > 38.3 C
• HR > 90bpm
• WCC > 12 or < 4 * 10*9/L
• RR >20/min
• Acutely altered mental state
• Hyperglycemia in absence of DM
If YES then
H/o or signs suggestive of new
infection
• Cough/sputum/chest pain
• Abdominal pain/distention/
diarrhea
• Line infections
• Dysuria
• Headache with neck stiffness
• Cellulitis/wound infection/septic
arthritis
If YES, patient has sepsis
Continued screening for severe sepsis
Signs of organ dysfunction
• SBP < 90mmHg or MAP < 65
• Urine output <0.5ml/kg/hr for 2 hrs
• INR >1.5 or APPT > 60s
• Bilirubin > 34mmlo/L
• Lactate > 2 mmol/L
• New need for O2 to keep SP02> 90%
• Platelets < 100 * 10*6/L
• Creatinine > 177mmol/L
NO: Treat for sepsis
YES: start severe sepsis care pathway
Severe sepsis care pathway
• O2: high flow 15L/min via non-
rebreathe mask target SP02 >94%
• Blood culture + bood tests
• IV antibiotics
• Fluid resuscitation-If hypotensive
bolus NS or RL 20ml/kg max
60ml/kg
• Serum lactate & Hb
• Catheterize and commence fluid
balance chart
 Pathogens in surgical infections
Mostly caused by endogenous bacteria.
Gram positive cocci
1. Staphylococci
2. Streptococci
Facultative anaerobics gram negative rods.
1. E.coli
2. Proteus
3. Klebsiella
4. Enterobacter and Serratia
 Pathogens in surgical infections

Obligate aerobes
1. Pseudomonas
2. Acinetobacter
Anaerobes
1. Bacteroides fragilis
2. Clostridium
Fungi involved also but it is mostly opportunistic invader mostly candida
genus isolated.
 Specific antimicrobials

 Penicillins
Anti staphylococcal and reduced activity against streptococcal and no activity against gram
negative rods or anaerobic bacteria
 Aminoglycosides
Active against gram negative enterobacteriaceae, anaerobes and streptococci
 Vancomycin
Active against gram postives and MRSA Methicillin Resistant Staphylococcus Aureus
 Carbapenems
Stable to b-lactamase and also gram positive
 Imidazoles mostly metronidazole
Against anaerobes
 cephalosporins
 Specific surgical infections

SSIs
• Superficial SSIs :- pyrexia, local erythema, pain,
excessive tenderness, site discharge
• Deeper SSIs : pyrexia, leukocytosis, organ dysfunction eg
prolonged post operative ileus
• Tx: cellulitis-antibiotics
abscess- drainage
 Specific surgical infections

UTIs
• Common; can be cystitis, pyelonephritis, perinephric abscess
• Catheterized px are at increased risk
• Organisms- E.coli, Klebsiella sp, Enterococcs faecalis, P. aeruginosa
• Cystitis may be asymptomatic
• Pyelonephritis: rigors, renal angle pain and tenderness
• Tx; ABCs- trimethoprim, gentamicin, co-amoxiclav,
fluoroquinolones
• Aseptic introduction and meticulous care of urinary
catheter helps prevent bacteria colonizing urinary tract
 Specific surgical infections

RTIs
• Both upper and lower RTIs, lung abscess, empyema
• Organisms; S. pneumonia, H. influenza others
E.coli, P. aeruginosa, MRSA (esp during or after mechanical
ventilation)
• Fever, tachypnea, cough, increased resp secretions,
breathlessness, confusion
• Tx; ABCs
• Abscess or empyema should be drained
• Physiotherapy, early mobilization, adequate pain relief in post op
important in prevention
 Specific surgical infections

Clostridium difficile infection

• Occurs when the normal microflora is disturbed by admin of ABCs
in px either pre-colonized with or exposed after ABCs to C. difficile
• Implicated ABCs; clindamycin, cephalosporins & Fluoroquinolones
• Disease common in elderly and in poorly cleaned hospitals
• Abdominal discomfort, profuse watery diarrhea, severe abdominal cramps,
rare toxic dilatation of the colon
• Colonoscopy; xtic yellow plaques, bleeding mucosa, islands of normal tissue (
pseudomembranous colitis )
• Dx; toxins in faeces by EIA or PCR
• Tx; mild/moderate ds- oral metronidazole, severe ds-oral vancomycin
• Emergency colectomy for fulminant colitis-life saving
 Infections treated by surgical mgt

These include;
• Abscess
• Necrotizing fasciitis
• Diabetic foot infections
• Gas gangrene
• Infections following trauma
• Tetanus
 Management
• The risk of surgical site infection rises in direct proportion
to the degree of microbial contamination of the wound
• Whenever possible, the focus of infection should be
identified by careful history-taking, clinical examination,
imaging and microbiological culture
• Collections of pus should be drained
• In many surgical infections,
-antibiotics are often an adjunct to surgical treatment, e.g.
-- drainage of abscesses,
--debridement, excision of infected tissue
-- lavage of a serous cavity
--Tetanus immunization status tetanus toxoid, (0.5 ml intramuscular to deltoid muscle)
of patients must be determined prior to elective surgery or following trauma
-- antibiotics Proper culture sensitivity
 ACUTE PYOMYOSITIS

lt is infection and suppuration with destruction of the skeletal muscle

commonly due to Staphylococcus aureus and Streptococcus
pyogenes, occasionally due to Gram-negative organisms.
• It is common in muscles of thigh, gluteal region, shoulder and arm.
• Precipitating factors are similar to necrotising fasciitis.
• Creatine phosphokinase will be very high and signifies acute phase.
• Renal failure is common.
• MRI is useful.
• Treatment is antibiotics, wound excision and compartment release
often with haemodialysis.
 ABSCESS
Types ABSCESS
1. Pyogenic abscess
2. Pyaemic abscess
3. Metastatic abscess
4. Cold abscess due to chronic infection like tuberculosis

Bacteria causing abscess

1. Staphylococcus aureus.
2. Streptococcus pyogenes.
3. Gram-negative bacteria (E. coli, Pseudomonas, Klebsiella).
4. Anaerobes.
Factors precipitating abscess formation
1. General condition of the patient: Nutrition, anaemia, age of the
patient
2. Associated diseases: Diabetes, HIV, immunosuppression
3. Type and virulence of the organisms
4. Trauma, haematoma, road traffic accidents
 ULCER

Definition: An ulcer is a break in the continuity of the covering epithelium, either

skin or mucus membrane due to molecular death.
Parts of an Ulcer
1. Margin: It may be regular or irregular. It may be rounded or oval.
2. Edge: Edge is the one which connects floor of the ulcer to the margin. Different
edges are:
• Sloping edge. It is seen in a h ealing ulcer.
Its inner part is red because of red , healthy
• granulation tissue.
• Its outer part is white due to scar/fibrous tissue.
• Its middle part is blue due to epithelial proliferation.
3. Floor: It is the one which is seen. Floor may contain discharge, granulation tissue
or slough.
4. Base: Base is the one on which ulcer rests. It may be bone or soft tissue.
ulcer
 Assessment of an Ulcer

• Cause of an ulcer should be found - diabetes/ venous I arterial/

infective.
• Clinical type should be assessed.
• Assessment of wound is important- anatomical site; size and depth
of the wound; edge of the wound;
• mobility; fixity; induration; surrounding area; local
• blood supply. Wound perimeter may be useful in
• assessing this.
CLINICAL EXAMINATION OF AN ULCER
History
• Mode of onset
• Duration
• Pain - its time of onset, progress, severity
• Discharge from ulcer
• History suggestive of associated disease I treatment history
Local examination of an ulcer
• Inspection
• Site of ulcer - arterial ulcer over the digits; venous ulcer over the malleoli; trophic ulcer over
heel I pressure points
• Size of ulcer
• Shape of ulcer
• Number
• Mar gin whether regular /irregular /welldefined I ill-defined
• Edge of ulcer
• Floor of the ulcer - floor is the one what is seen.
• It rests on the base. (Base is not seen; it is only
• felt). Red color in floor - healing ulcer; slough
• with pale I purulent discharge - nonhealing ulcer
• or tubercular; wash leather slough - syphilitic
• ulcer/ proliferative and nodular floor - squamous
• cell carcinoma; pigmented - melanoma,
• pigmented basal cell carcinoma
• • Discharge from ulcer bed - serous, serosanguinous,
• bloody, purulent; color of discharge -
• greenish in pseudomonas infection
• • Surrounding area to be examined for inflammation,
• oedema, eczema, scarring, pigmentation
• • Inspection of the entire part/ limb
• Palpation
• • Tenderness over edge, base and surrounding area
• • Warmness over surrotmding area
• Edge palpation for induration
• • Palpation of base for induration/ fixity
• • Depth of ulcer - trophic ulcer is deep with bone
• as its base - often it is measured gently in mm
• • Bleeding on palpation and touching
• • Palpation for deeper structuresand its relation
• to ulcer
• • Surrounding skin and tibia/ calcaneum/ other
• related bones for thickening
• • Examination of adjacent joint for mobility
• • Examination of regional lymph nodes is essential
• - tenderness (acute infection), mobility, consistency
• may be hard (carcinoma metastasis) I firm/
• soft and non tender (inflammatory); fixity
• (malignancy); ulceration or fungation (malignancy);
• sinus (non specific, tuberculosis or
• carcinoma)
• Specific systems
• Examination of arterial pulse, peripherally in relation
• to ulcer and cardiovascular system for murmur
• Examination for varicose veins in standing position
• Examination of the abdomen for splenomegaly (sickle
• cell disease); hepatomegaly
• Examination of spine (gibbu s, paraspinal spasm,
• movements) and neurological system like sensation and
• muscle power
 Management of an Ulcer
• Cause should be found and treated
• Correct the deficiencies like anaemia, protein and vitamins deficiencies
• Transfuse blood if required
• Control the pain
• Investigate properly
• Control the infection and give rest to the part Care of the ulcer by debridement,
ulcer cleaning and dressing is done
• Remove the exuberant granulation tissue
• Topical antibiotics for infected ulcers only like framycetin, silver sulphadiazine,
mupirocin
• Antibiotics are not required once healthy granulation tissues are formed
• Once granulates, defect is closed with secondary suturing, skin graft, flaps.
Dressing of an ulcer is done

• To keep ulcer moist

• To keep surrounding skin dry
• To reduce pain
• To soothen the tissue
• To protect the wound
• As an absorbent for the discharge
 Investigations
• Total count is increased.
• Urine sugar and blood sugar is done to rule out diabetes.
• USG of the part or abdomen or other region is done when required.
• Chest X-ray in case of lLmg abscess.
• Gallium isotope scan is very useful.
• CT scan or MRl is done in cases of brain and thoracic abscess.
• Investigations, relevant to specific types: Liver function tests, P02
and PC02 estimation, blood culture.
 Reference books

 Sabiston’s Textbook of surgery-18th edition

 Davidson’s Principles and practice of surgery-6th edition
 Bailey and Love’s Short practice of surgery-26th edition