MEDICAL & SURGICAL

PATHOLOGY 1 POSTSURGICAL
INFECTIONS
BACKGROUND

• 19th century : attempts to reduce the surgical site infection (SSI) rate
 Hamilton – study of epidemiology and prevention of ”surgical fever”
 Lister – introduction of antiseptics (phenol) for surgical instruments and wounds

• Today’s problems :
 More surgeries and more complex (transplant , advanced oncologic surgery, etc.)
 Aged population and with a high incidence of obesity (and related diseases : diabetes, hypertension)
 Wide use of prosthetic devices in orthopaedic and cardiac surgery, hernia surgery (predispose to microbial
contamination and infection)

• 2-5% of all the surgical patients in the US, where SSI is the most common nosocomial infection and S.
aureus is the main pathogen
PATHOGENESIS

Microbial
characteristics
- Virulence
- Burden

Wound
Host
- Haemostasis
- Immune status
- Vitality
- Comorbidities
- Foreign bodies
 • Source :
1) Endogenous contamination : Cutaneous flora next to the incision site (Gram-positive
cocci). Less frequent : inoculation from other sites by hematogenous spread.

MICROBIAL 2) Exogenous contamination (occasionally) : Surgical personnel, operating room

environment, surgical instruments

CHARACTERISTIC • Burden :

S
- The higher, the greater the risk; with adequate antibiotic prophylaxis, > 100.000
microbes are required to cause SSI but the threshold diminishes in the presence of
prosthetic implants

• Virulence : surface components that facilitate adhesion, exo and endotoxins, biofilm
generation, surface capsule that prevents opsonization/phagocytosis
 MICROBIOLOGY OF SSI

Most frequent source - skin Abdominal surgery + lower

surrounding the incision site limbs surgery : Gram-
: negative bacilli Lower GI tract, female
• E. Coli
genital tract, oropharynx :
Gram-positive cocci anaerobes
• Klebsiella spp
• S. epidermidis
• S. aureus
• Enterococcus spp
RISK
FACTORS
FOR SSI
SURGICAL WOUNDS CLASSIFICATION

CLEAN-CONTAMINATED
CLEAN WOUNDS WOUNDS
• Non-traumatic • Non-traumatic

• No breaks in sterile technique • Minimal breaks in sterile technique

• Without opening of the digestive/genitourinary or • Opening of the digestive/genitourinary or respiratory tract

respiratory tract
• No significant spilling of contaminated contents
• No inflammatory process
• Require antibiotic prophylaxis
• Do not require antibiotic prophylaxis
• Risk of infection: 5% aprox.
• Risk of infection < 2%
• E.g. : colectomy, histerectomy, prostatectomy, lung
• E.g. : skin surgery, hernioplasty without mesh, thyroid resection
surgery, breast surgery
SURGICAL WOUNDS CLASSIFICATION

CONTAMINATED
• Open, fresh, traumatic wounds (< 6 h of evolution)
• Major break in sterile technique
• Significant spillage of gastrointestinal contents
• Opening of the biliary/genitourinary tract in the presence
of infection
DIRTY
• Open traumatic wounds of > 6 h of evolution, with retention of
devitalized tissue/foreign bodies
• Acute bacterial infection /perforated viscus
• Abscesses
• Requires antibiotic treatment NOT prophylaxis

• Acute non-purulent infection • Risk of infection: 30-40%

• Requires antibiotic prophylaxis • E.g. : peritonitis, intraabdominal abscesses, open fractures

• Risk of infection : 12-15%

• E.g. : cholecistectomy for acute cholecystitis, non-

perforated appendicitis
CLASSIFICATIO
N OF SSI
INCISONAL
SSI

Deep incisional SSI

Superficial incisional SSI
Abscess of the rectus abdominis sheath
ORGAN/SPACE SSI

•Postoperative intraabdominal abscess

•Transgastric endoscopic drainage
DIAGNOSIS OF SSI

• Timing : usually developed by the 4th-5th postoperative day

• Superficial/deep SSI : Inflammatory signs and symptoms (erythema, heat, edema, pain, loss of function)
• Cavitary SSIs : signs and symptoms related with the dysfunction of the contained organs (adynamic ileus,
respiratory distress)
• Uncontrolled or severe infection : systemic signs and symptoms of inflammatory process/sepsis

• Exceptionally, some infections may develop during the first 24 postoperative hours – Clostridium
perfringens, S. pyogenes
• Culture of wound exudate : whenever possible, especially for deep and organ/space SSI
• Imaging techniques (ultrasonography, CT scan) : especially for organ/space SSI; occasionally for deep SSI
 TREATMENT

 Superficial SSI :
• Wound opening, irrigation, local wound care
• Antibiotics in case of extensive wound erythema and/or signs of systemic infection

 Deep SSI :
• Surgical exploration, debridement, antibiotics

 Organ/space SSI
• Surgical exploration, debridement, drainage
• In selected cases (accessible intracavitary abscesses) : placement of radiologically-guided percutaneous drains
• Antibiotics

Debridement : removal of the contents from a contaminated/infected space (exudate, foreign bodies, devitalized tissue)
FOOD FOR THOUGHT

Annals of Surgery, 2019

Probiotics (according to WHO) : live microorganisms which confer beneficial effects to the host
when given in sufficient quantities.
Prebiotics are food ingredients, which escape digestion in the upper gastrointestinal tract to stimulate
the growth or activity of selective bacterial genera in the colon.
Synbiotics = combination of pre and probiotics in a single product
WHAT ABOUT TOOTH EXTRACTIONS ?

Year of the review 2012 – not updated yet !