SURGICAL INFECTIONS

AND
PRINCIPLES OF MANAGEMENT

PREREQUISITE KNOWLEDGE
Pathogenicity of microorganisms
Host defense processes that combat
microorganisms
Factors that affect host-pathogen
interaction
The inflammatory process
Pathogenesis of bacterial infections

1 - DEFINITION
1.1 - Infections that develop following
surgery or traumatic injury
1.2 - Infections that require surgical
(operative) treatment for their cure

2 - CHARACTERISTICS
2.1 Most surgical infections are the
result of damaged host defenses,
especially injury to the epithelial
barrier
Wound infections
Cellulitis
Subcutaneous abscess

2 - CHARACTERISTICS
2.2 - Mechanical obstructive factors
may underlie the infection
Cholecystitis
Appendicitis
Urinary tract infections

2 - CHARACTERISTICS
2.3 There are immunologic defects,
acquired through trauma or tumour
or caused by nutritional deficiency
or the systemic effects of trauma

2 - CHARACTERISTICS
2.4 - The pathogens are frequently mixed,
involving aerobes & anaerobes, and
usually originate from the patients
own flora
Intra-abdominal abscesses

3 - TYPES OF INFECTIONS
3.1 - Soft tissue infections
3.1.1 - Abscess presence of dead tissue

Subcutaneous
Breast
Perianal
Felon (paronychia)
Carbuncle

3 - TYPES OF INFECTIONS
3.1 - Soft tissue infections
3.1.2 - Necrotizing soft tissue infections
Clostridial myonecrosis / gas gangrene
Necrotizing fascitis (clostridial & non-clostidial

3.1.3 - Surgical wound infection

3 - TYPES OF INFECTIONS
3.2 Intra-abdominal and
Retroperitoneal Infections
Cholecystitis
Appendicitis
Pyelonephritis
Diverticulitis
Peritonitis
Intra-abdominal and
Retroperitoneal abscesses

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3 - TYPES OF INFECTIONS
3.3 Postoperative urinary and
respiratory tract infections and
bacteraemia

11

4 - SOURCES of MICROBIAL
CONTAMINATION
4.1 Direct inoculation
Preoperatively

Patients residual flora or contaminated skin

Hands of surgeon or assistants
Contaminated instruments or surgical material
Contaminated procedure

Postoperatively

Flora adjacent to operative site

Contamination during wound care or dressing by
medical staff
Drains, catheters, intravenous lines
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4 - SOURCES of MICROBIAL
CONTAMINATION
4.2 Airborne contamination occurs
During surgery
In burns and
Open wounds

Contaminants originate from

Skin, mucus membrane and clothing of
patient or staff
Failure of correct air handling during
operation
13

4 - SOURCES of MICROBIAL
CONTAMINATION

4.3 Haematogenous and lymphatic

seeding

Peroperatively
Inapparent infection (e.g. UTI, chest)
Intravascular lines
Postoperatively
Infection at other sites
Intravascular lines

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5 FACTORS DETERMINING the

SEVERITY of POSTOPERATIVE
INFECTION
5.1 Patient factors
Host immunity, immunosuppression
Nutritional status
Extremities of age
Diabetes mellitus
Debility (malignancy, hepatic dysfunction,
uraemia)
Anaemia
Nephrotic syndrome

15

5 FACTORS DETERMINING the

SEVERITY of POSTOPERATIVE
INFECTION
5.2 Surgical factors
Degree of tissue trauma
Devitalization
Dead space
Haematoma
Presence of foreign body

16

5 FACTORS DETERMINING the

SEVERITY of POSTOPERATIVE
INFECTION
5.3 Microbial factors
Microbial load
Enzymes produced by microbe (e.g.
hyaluronidase, coagulase)
Resistance patterns of organisms

17

6 CLASSIFICATION of OPERATIVE
WOUNDS
6.1 Clean

Infection rate
12%

6.2 Clean-contaminated

<10 %

6.3 Contaminated

15-20%

6.4 Dirty

40+ %
18

6 CLASSIFICATION of OPERATIVE
WOUNDS

6.1 Clean wound

Non-traumatic
No inflammation
No break in technique
Respiratory, GI and GU tracts not
breached

19

6 CLASSIFICATION of OPERATIVE
WOUNDS

6.2 Clean-contaminated wound

Non-traumatic
A break in technique has occurred
Respiratory, GI or GU tract has been
breached
But no significant spillage has occurred

20

6 CLASSIFICATION of OPERATIVE
WOUNDS

6.3 Contaminated
Fresh traumatic wound from clean source
Major break in technique
Gross non-purulent spillage from a viscus

21

6 CLASSIFICATION of OPERATIVE
WOUNDS

6.4 Dirty
Traumatic wounds from dirty source
Faecal contamination
Foreign bodies
Devitalized viscus
Pus from any source encountered during
surgery

22

7 - DIAGNOSIS
7.1 Local manifestations of acute
inflammation
Red, hot, painful swelling;
Fluctuant if superficial abscess
Purulent or serous wound discharge
Local features specific to anatomical
areas

23

7 - DIAGNOSIS
7.2 Systemic manifestations of
infection
Fever, chills, rigors sweating
Tachycardia, hypotension
Multiple system organ failure

7.3 Elevated WBC count

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7 - DIAGNOSIS
7.4 Imaging: U/S, X-ray and CT
Findings of inflammatory tissue changes
and abnormal fluid collections

7.5 Microbiological studies of

Body fluids
Wound discharges
Inflammatory fluid collections

7.6 Biopsy
25

8- PRINCIPLES of TREATMENT
8.1 Prevention
Shorten preoperative hospital stay
Vigorous preop diagnosis and treatment of
predisposing conditions and distant infections
Preoperative antimicrobial shower
Hair removal by clipping immediately before op
Vigilance for break in aseptic technique
Meticulous surgical technique

26

8- PRINCIPLES of TREATMENT
8.1 Prevention

Meticulous surgical technique

Gentle tissue handling

Minimize tissue trauma and necrosis
Ensure good haemostasis, avoid haematomas
and seromas
Limit sutures and ligatures (foreign bodies)
Avoid drainage if possible
Meticulous skin closure

Preventive antibiotics when indicated

27

8- PRINCIPLES of TREATMENT
8.2 Surgical Treatment
Surgical drainage of localized collection of pus
and all dead and devitalized tissue
Excision of infected organs and extremities
Bypassing an area of infection

8.3 Antibiotic therapy

8.4 Immunotherapy
8.5 Prophylactic antibiotic therapy
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8- PRINCIPLES of TREATMENT
8.5 Prophylactic antibiotic therapy,
indications contd

High risk gastroduodenal procedures: gastric ca,

ulcer, obstruction or bleeding
High risk biliary procedures: pts > 60 yrs, operations
for acute inflammations, CBD stones, or jaundice in
pts with prior biliary tract operations or endoscopic
biliary manipulations
Resection and anastomosis of the colon or small
intestine
Cardiac procedures through a median sternotomy
Vascular surgery of the lower extremities or
abdominal aorta
29

8- PRINCIPLES of TREATMENT
8.5 Prophylactic antibiotic therapy,
indications contd

Amputation of an extremity with impaired blood

supply, particularly in the presence of a current or
recent ischaemic ulcer
Vaginal or abdominal hysterectomy
Primary caesarian section
Operations entering the oropharyngeal cavity in
continuity with neck dissection
Craniotomy
The implantation of any permanent prosthetic device
30

8- PRINCIPLES of TREATMENT
8.5 Prophylactic antibiotic therapy,
indications contd

Any wound with known bacterial contamination

Accidental wounds with heavy contamination and
tissue damage: penetrating abdominal injuries and
fractures
Injuries prone to clostridial infection because of
extensive devitalization of muscle, heavy
contamination, and/or impairment of blood supply
Presence of pre-existing valvular heart damage, to
prevent the development of bacterial endocarditis
31

9 SPECIFIC INFECTIONS
Cellulitis, furuncle and carbuncle
lymphangitis
Surgical wound infection
Gas gangrene, tetanus
Subcutaneous, breast,perianal and
perirectal abscess
Peritonitis, intra-abdominal abscess

32

Post-Operative Wound
Infection
This is contamination of a surgical
wound during or after a surgical
procedure.
The infection is usually confined
superficially to the subcutaneous
tissue.
If it extends below the fascia, it is
considered a deep infection.
33

Source of infection:
The source of contamination in more
than 80% cases is the patient
(endogenous).
Organisms may come from the
patients skin or transected viscus.
In about 20% of cases, the source is
from the environment, operating staff
or unsterile surgical equipment
(exogenous).
34

Clinical findings:
The infection usually becomes evident
on the 5th-7th postoperative day. The
following clinical features may
accompany the infection.
- Fever
- Wound pain
- Wound edema and induration
- Local hotness and tenderness
- Wound/stitch abscess
- Serous discharge
- Crepitation occasionally

35

Management:
- Remove stitches to allow drainage
- Local wound care
- Antibiotics only if systemic
manifestations or signs of local
spread accompany

36

Abscess
An abscess is a localized collection of
pus.
It contains necrotic tissue and
suppuration from damage by the
bacteria, and white blood cells.
It is surrounded by area of inflamed
tissue due to the bodys response to
limit the infection.
37

Etiology:
Pyogenic organisms, predominantly
staphylococci are the leading causes.
These organisms lead to tissue
necrosis and pus formation.

38

Clinical features:
Patients with an abscess anywhere in the
body may present with the following findings.
- Clinical features of inflammation when
superficial (Heat, pain, edema, redness and
loss of function)
- Local fluctuation if superficially located.
- Spontaneous discharge and sinus formation
- Systemic manifestations like fever,
sweating, tachycardia
- Chronicity especially in granulomatous
infection like mycobacteria,
39

Treatment:
- Primary treatment is drainage of the
abscess by making incision
- Debridement and curettage to break
all septations and loculations
- Delayed primary or secondary closure
is preferred
- Antibiotics should not be given until
systemic symptoms or signs of spread
occur
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Cellulitis
Is an inflammation of the
subcutaneous tissue characterized by
invasion without definite localization.
Thin exudate spreads through the
cleavage planes of tissue spaces.
It usually involves the extremities and
identifiable portal of entry is
detectable.
41

Etiology
The most common etiologic
organisms are :
Beta hemolytic streptococci
Staphylococci.
Clostridium perfringens

42

Clinical features
Identifiable portal of entry which can be a
surgical wound, puncture site, skin ulcer or
dermatitis.
Local signs of inflammation, which may be
very intense.
Poorly defined brown-red edema.
Blebs and bullae in severe cases ; tissue
destruction and ulceration may follow.
Centeral necrosis and suppuration may occur
late.
Systemic signs of bacteremia and toxemia due
43
to spread and toxin release.

Management
Rest to limit spread of infection and
pain.
Elevation of the involved limb.
Hot ,wet pack
High dose broad spectrum antibiotics
IV.

44

Impetigo
This is a skin infection characterized by
a series of intraepithelial abscesses
which present as multiple small
pustules coalescing together. Later
these pustules form lesions with
erosion and crust formation.
The disease is contagious in nature.
Etiology: The causative agents are
streptococci and staphylococci.
45

 Clinical Pictures:
- Series of small intra epithelial
abscesses , multiple
- Bullous lesions
- Skin erosion and
- Crust formation.

46

 Management:
- Local care
- Careful washing with antiseptic
soap
- Local antibiotic ointments like
neomycin if available
- Systemic antibiotics like cloxacilline
only in resistant cases
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Furuncle (Boil)
Furuncle is an acute infection of hair
follicles with Para follicular
inflammation.
It commonly occurs over the axillae,
back of the neck and buttocks.
Poor hygiene, immune suppressive
diseases and irritation are known
contributing factors.
48

Etiology:
The causative agents are staphylococci
aureus.
Clinical feature:
- There is an intense local irritation of acute
onset
- Painful firm, reddish, round swelling initially,
which later becomes fluctuant
- Suppuration and central necrosis occurs later
- The condition subsides and is self-limited to
recur in multiple lesions (chronicity)
49

Treatment:
It may subside spontaneously
without suppuration (Blind boil)
Incision /Excision if complicated
Antibiotics

50

Carbuncle
Carbuncle is an infective gangrene of
subcutaneous tissue which
commonly occurs in patients with
diabetes and other immune
suppressive conditions.
It is commonly found over the nape
of the neck.

51

Etiology:
It is caused by staphylococcus aureus.
Clinical Feature:
Formed by multiple furuncles
Pain
Erythema
Induration
Progressive suppuration of thick pus.
Tissue loss with shallow and deep ulcer
surrounded by smaller areas of necrosis.
52

Treatment:
Adequate systemic antibiotics in
early stages
Aggressive debridement
Local wound care
Detect and treat predisposing factors
like diabetes mellitus

53

Pyomyositis
Pyomyositis is an acute bacterial infection
of skeletal muscles with accumulation of
pus in the intra-muscular area.
It usually occurs in the lower limbs and
trunk spontaneously or following
penetrating wounds, vascular
insufficiency, trauma or injection.
Poor nutrition, immune deficiency, hot
climate and intense muscle activity are
highly associated factors.
54

Etiology: The most common causative

agent is Staphylococcus aureus.
Streptococci can also be detected in acute
form.
Clinical Features: It usually has subacute onset and can present with
Localized muscle pain and swelling, late
tenderness
Induration, erythema and heat
Muscle necrosis due to pressure
Fever and other systemic manifestations later
after some days
55

 Treatment:
Immediate intravenous antibiotics
before surgery
Surgical drainage of all abscess
Excision of all necrotic muscles
Supportive care

56

Necrotizing fasciitis
This is an acute invasive infection of the
subcutaneous tissue and fascia characterized by
vascular thrombosis, which leads to tissue
necrosis.
The skin is secondarily affected.
It is idiopathic in origin but minor wounds, ulcers
and surgical wounds are believed to be initiating
factors.
The condition is described as "Meleneys
synergistic gangrene" if it occurs over the
abdominal wall and Fourniers gangrene if in
the scrotum and perineal area.
57

Bacteriology:
Mixed pathogens of the following
microorganisms are usually cultured.

Streptococci
Staphylococci
Gram negative bacteria
Anaerobes and
Clostridia

58

Clinical Features:

Sudden onset of localized pain

Rapidly spreading inflammation
Spread along chemic fascial planes
Hemorrhagic bulla and edema
Skin devascularization
+/- Crepitations
+/- Muscle necrosis
Systemic signs of toxemia
59

Management:
Broad spectrum combined antibiotics
Gentamycin or Ceftriaxone for coverage
of aerobic organisms. AND
Cloxacilline or chloramphenicol or
Metronidazole for coverage of anaerobic
organisms.
Circulatory support with intravenous
fluid as much as required and transfusion
of cross matched blood when necessary.
60

 Surgery as soon as possible.

The following surgical procedures may be
required:
- Debridement and excision of all dead
tissue
- Multiple incisions for drainage
- Repeated wound inspection
- Skin graft may be needed later if
extensive skin involved.
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CLOSTRIDIAL
INFECTIONS

1. Tetanus

Tetanus is a non-invasive infection caused

by anaerobic micro-organisms which
requires favorable wounds like abortions,
lacerations, injections, open fractures,
burns, deep contused wounds with dead
tissues and foreign body.
It can practically be eliminated by tetanus
vaccine immunization if properly initiated
and maintained.
62

Etiology:
Clostridium tetani, a gram-positive
rod found in soil and manure is the
causative agent.
It requires anaerobic environment for
growth, invasion and elaboration of
toxin, tetano-spasmin, for its
dramatic virulence.

63

Clinical Features:
- Can be latent with healed and
forgotten wounds
- Local or generalized weakness
- Stiffness or cramping pain on the back,
neck and abdomen
- Difficult of chewing and swallowing
- Tonic muscles spasms
- Sardonic smile as evidence of onset of
tonic spasm.
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C/F
Severe pain and opisothonus due to
reflex convulsion of all muscles
Progressive difficulty of respiration
Fever, tachycardia, cyanosis
Respiratory failure and death due to
repeated cyanotic convulsive
attacks.
Fear of water, sound & light.
65

Treatment:
Meticulous surgical excision of the
wound regardless of immunization state to
eliminate the bacterial infection and the
dead contaminated tissue.
Isolation, quietness and comfort
Sedation with chlorpromazine up to
200mg IM/day, barbiturates or diazepam
50mg IV under close follow up and
observation for central signs of drug over
dose.
66

 Antibiotics: crystalline penicillin

is the drug of choice for parenteral
medication.
Tetracycline can be an alternative
antibiotic for oral therapy.
Intensive nursing care
Naso-gastric tube for feeding to
maintain protein balance
67

 Immunization
Respiratory support and consider
tracheostomy if spasms becomes frequent
leading to cyanosis.
Human antitetanus globulin if available to
neutralize circulating toxin.
Active immunization with 0.5 ml of
tetanus toxoid if the patient is not
immunized or the wound is tetanus prone.
68

Prevention:
Prevention of clinical tetanus depends on
adequate immunization of the population.
Careful surgical management of all
traumatic wounds, even those which
appear to be minor.
Patients with grossly contaminated wounds
and no or unclear history of immunization
should receive an intramuscular antitoxin
therapy.
Active immunization with tetanus toxoid
should also be started.
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2. Gas Gangrene
Gas gangrene is another clostridial
infection associated with soft tissue
infection (Clostridial myonecrosis). It is a
rare but devastating infection
characterized by muscle necrosis and
systemic toxicity due to the elaboration
and release of toxins. It usually follows
wounding with trauma or surgery and
requires factors contributing to tissue
hypoxia like foreign bodies, vascular
insufficiency or occurs as a complication of
amputation.
70

Etiology:
Clostridium perfringens is responsible
for over 80% of cases.
More than one species can be
isolated or polymicrobial infection
with other microorganisms can occur.

71

Clinical features:
Sudden and persistent severe pain at
wound site.
Localized tense edema, pallor and
tenderness
Gas noted on palpation or radiographs
Progressive brownish discoloration of
skin and hemorrhagic bullae formation
Dirty brown discharge with offensive,
sweetish odor.
72

 Severe systemic manifestations

including fever, tachycardia,
hemolytic anemia, hypotension, renal
failure and finally death.
Grams stain from the discharge can
be diagnostic.

73

Management:
Surgery is most important component.
Extensive, wide excision of involved
muscles.
Amputation of an extremity may be needed.
Antibiotics: high dose penicillin is the
preferred drug.
Supportive measures including:
- Intravenous infusions
- Blood transfusions
- Close monitoring and follow up
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