Professional Documents
Culture Documents
Surgical Infections
Infection:
systemic and local signs of inflammation,
bacterial count more than 10*5cfu/ml
Definition
Bacteraemia is unusual following superficial SSI but common
after anastomotic break down.
dangerous if the patient has prothesis.
Causes of reduced host resistance to
infection
Two of
Hyperthermia >38 degree C or hypothermia <36
Tachycardia (>90) or tachypnoea(>20/min)
White cell >12x10 9 or < 4 x 10 9/l
Sepsis- systemic manifestation of SIRS with documented
infection; common after anastomotic breakdown
Severe sepsis or severe sepsis syndrome- sepsis with one or
more than one organ failure
MODS is the effect the infection produces systemically
MSOF is the end stage of uncontrolled MODS
1. Community-Acquired - primary
active process that were initiated before the patient
presented for treatment
acquired from community or endogenous
2. Hospital-Acquired- Secondary
All infections that occur after surgical procedures
acquired from hospital or exogenous
Community-Acquired
Skin/soft tissue
Cellulitis: Group A strep Tetanus
Abscess/furuncle: Staph Hand infections
aureus Foot infections
Necrotizing: Mixed Biliary tract infections
Hiradenitis suppurativa: Peritonitis
Staph aureus
Viral infections
Lymphangitis: Staph aureus
Gangrene : synergistic
Hospital-Acquired
SSI (Wound infection)
Pulmonary
Urinary Tract
Intra-abdominal
Empyema
Foreign-body associated
Fungal infection
Multiple organ failure
Cellulitis
Spreading inflammation of
subcutaneous and fascial
plane
Streptococcus pyogenes,
others- klebsiella,
pseudomonas, E.coli
Furuncle
Acute staphylococcal
infection of hair follicles
with perifolliculitis
suppuration and central
necrosis
Hiradenitis
Chronic infective and
fibrous disease of skin
bearing apocrine gland
which ones into hair follicles
Sites of apocrine sweat
glands
Axilla,areola,umbilicus,
groin, perineum
Carbuncle
Charcoal
Infective gangrene of skin and subcutaneous tissues
Staphylococcus aureus main culprit
Nape of neck and back
Common in diabetic
Necrotizing
Spreading inflammation of
the skin, deep fascia and
soft tissues with extensive
tissue destruction
80% polymicrobial- streptococcus pyogenes ,coliform, gram
negative organism, anaerobes
Limbs, lower abdomen, groin, perineum
Common in old age, smoking, diabetics, immunotherapy and
Hiv patients.
Trauma is a common precipitating factor
Clinical features
Sudden swelling, pain in the part with oedema
Foul smelling discharge
Crepitus with subcutaneous emphysemas, skin vesicles,
extensive necrosis and cutaneous microvascular thrombosis
Oliguria
Jaundice
Toxemia, sirs, MODS,
Management
IV fluids,
Antibiotics
Resuscitation, critical care ( oxygen, intubation and ventilator
Wound excision
Skin grafting
Lymphangitis
Non supperative and poorly
localised
Painful red streaks in
affected lymphatics
Often accompanied by
painful lymph nodes
Cellulitis and lymphangitis
Non-suppurative , poorly localized
Commonly caused by streptococci, staphylococci or clostridia
SIRS is common
Blood cultures are often negative
Abscess
Localized collection of pus in a cavity lined by granulation
tissues
Pus- dead wbcs , multipying bacteria, toxins and necrotic
material
abscess
Staphyloccus aureus
Streptococcus pyogenes
Gram negative bacteria
anaerobes
Factors precipitating abscess formation
General condition of pt
Associated disease
Types of organism
Others- trauma,
Complication of abscess
Bacteremia
septicaemia
pyaemia
Antibioma
Sinus and fistula formation
Specific complication
Abscesses
Abscesses need drainage and curettage
Modern imaging technique may allow guided aspiration
Antibiotics if not localised
Healing by secondary intention is better
Gas gangrene
Caused by Clostridium
perfringens
Gas and smell are
characteristic
Immunocompromised
patients are most at risk
Antibiotic prophylaxis is
essential when performing
amputation
Surgical Site Infection
SSI is an infected wound or deep organ space
Infection occurs within 30 days after the operative procedure if no implant is left in
place or within one year if implant is in place and the infection appears to be
related to the operative procedure
infection involves any part of the body, excluding the skin incision, fascia, or
muscle layers, that is opened or manipulated during the operative procedure
and
patient has at least one of the following:
a. purulent drainage from a drain that is placed through a stab wound into the organ/space
b. organisms isolated from an aseptically obtained culture of fluid or tissue in the
organ/space
c. an abscess or other evidence of infection involving the organ/space that is found on
direct examination, during reoperation, or by histopathologic or radiologic examination
d. diagnosis of an organ/space SSI by a surgeon or attending physician.
Source of SSI Pathogens
1. Endogenous flora of the patient
SSI RISK
Risk factors
1. surgical factors
A. Type of procedure
B. Degree of contamination
C. Duration of operation
D. Urgency of operation
2. Patient-specific factors
Patient-specific factors can be further defined as either local and
systemic
Patient-specific factors
local systemic
High bacterial load Advanced age
Wound hematoma Shock
Necrotic tissue Diabetes
Foreign body Malnutrition
Obesity Alcoholism
Steroids
Chemotherapy
Immuno-compromise
Wound Classification
according to the degree of contamination
Sources:
Air in operation room
Instruments
Surgeons and staff
Patients flora. Largest inoculum is from areas that are heavily
colonized e.g. bowel, female GUT, diseased biliary tract
This factor is modifiable
2. Virulence of the bacteria
Shower and scrub the surgical site with antiseptic soap the evening prior
to operation
Caps, masks gowns, surgical gloves Insert drains through separate stab
incision
Sterilization of the instruments
Leave skin and subcutaneous tissue
Gentle handling of tissue
open if dirty
Good haemostasis
Sterile dressing
Topical ointments
3. Preventive antibiotic therapy
Emperical cover against expected pathogens till
sensitivities available
Tissues or pus sent for culture prior to that
Single shot antibiotics at the time of induction of -
Repeat IV only in prosthetic surgery, long surgery(if
excessive blood loss) Repeated 8 hrs and 16 hrs later
Continue if unexpected contamination
Benzylpenicillin if suspected clostridium infection
4. Enhancement of host defense
1. Increase oxygen delivery
2. Optimizing core body temperature
3. Blood glucose control
4. Correct any coexisting condition e.g malnutrition,
anemia
Advances in control of infection in
surgery
Aseptic operating theatres
Antibiotics have reduced the post operative infection rates in
elective and emergency cases
Techniques of delayed /secondary closures remain useful in
contaminated wounds
Choice of antibiotics for prophylaxis
Empirical coverage against expected
pathogens with local hospital guidelines
Single shot IV at induction
Avoiding surgical site infections
Wash hands between patients
Minimal patients stay
Avoiding preoperative shaving
Standard antiseptic skin preparation
Attention to theatre techniques and decipline
Avoid hypothermia preoperatively and ensure
supplemental oxygenation in recovery