What is new in

management of
Surgical Infection

Prof. Ravi Kant

Contents:

Introduction
Types of surgical infections
Definition of SSI
Types SSI
Recent management of SSI
sepsis
Peritonitis

Soft tissue/wound Infictions.

Third most reported nosocomial

infections
16% of all reported nosocomial
infections
Most common surgical patient
nosocomial infection (38%)

Soft tissue/wound Infictions.

2/3

involved surgical incision

1/3 deep structures accessed
by incision
Deaths in patients with
nosocomial infections77%
related to infection.
EWMA Journal 2005; 5(2): 11-15.

Introduction

< 1900= 70-80% mortality for

wound infection
>1900: Ignaz Semmelweis and
Joseph Lister = antiseptic surgery

Introduction
Surgery, trauma, non-trauma
local invasion can lead to
bacterial insult.
Once present, bacteria, initiate
the host defense processes.
Inflammatory mediators
(kinins, histamine, etc.) PMNs
arrive, etc.

Introduction
Surgical infections
surgical wound itself or in
other systems in the patient.
They can be initiated not only by
damage to the host but also by
changes in the hosts physiologic
state.

Infections
Two

main types
Community-Acquired
Hospital-Acquired

Community-Acquired
Skin/soft

tissue
Cellulitis: Group A strep
Abcess/furuncle: Staph aureus
Necrotizing: Mixed
Hiradenitis suppurativa:Staph aureus
Lymphangitis: Staph aureus

Cellulitis

Furuncle

Necrotizing

Hiradenitis

Lymphangitis

Breast Abscess

Peri-rectal abscess

Gas Gangrene

Paronychia

Diabetic foot infection

Biliary Tract
Usually

result from obstruction

Usual suspects:
E. coli, Klebsiella, Enterococci
Acute Cholecystitis
GB

empyema

Ascending

cholangitis

Community-Acquired
Viral
Hepatitis
HIV/AIDS
Tetanus

Hospital-Acquired
Post-operative
At the surgical site
Systemic.

Infected Vascular Graft

Inguinal incision is independent risk

factor
Length of case and blood loss
Prosthetic grafts 10%-20%
S. Aureus

Gas gangrene

Beta hemolytic strept

Clostridial perfringes (gram pos
rods) rare
50% polymicrobial
Rapid lysis of tissues with relatively
little response from host
Endotoxin

Gas gangrene

Aggressive debridement &

antibiotics
Repeat antibiotics

Catheter Sepsis
80%

of cases, colonized catheters

had been inserted by inexperienced
and experienced residents
Key is to identify before sepsis
develops
Stapylococcus epidermis, S. Aureus,
yeast

Burn Infections
Necrotic

tissue readily colonized

High bacteria counts are NOT
a reliable indication of an infected burn
Histological examination to determine
invasiveness
TX: debridement and antibiotics

Hospital-Acquired
Pulmonary
Pneumonia
Non-ventilator
Ventilator
Aspiration

associated

associated

Hospital-Acquired
Urinary

Tract
Diagnosis
Usual suspects
Pseudomonas, Serratia,
other

Hospital-Acquired
Foreign-body

associated

Sites
Catheters
Lines
Prosthetics/grafts

Hospital-Acquired
Wound

infection & SSI.

Surgical wounds are healing

by
1)

Primary intention
2) Secondary intention
3) Delayed primary intention

Incidence of SSIs closure/delayed

closure of an infected wound
Opening and re-closure times
Opening and
once
Opening and
two days
Opening and
four days
Opening and
nine days

re-closure at

Re-infection
rate %
50

re-closure after

20

re-closure after

re-closure after

10

[Gottrup, F. Wound healing and principles of wound closure. In: Holstrm H, Drzewieck KT (Eds).
The Scandinavian Handbook of Plastic Surgery. Malmoe: Studenterliteraturen, 2005

Definition of SSI
The

CDC : =< 30 days of

surgery (or within a year in
the case of implants)

Mangram . Guideline for prevention of surgical

site infection, 1999. Infect Control Hosp Epidemiol 1999;

classificationincisional
surgical site infections

Superficial
Deep
Organ/space

superficial incisional
surgical site infections
<

30 days of procedure
involve only the skin or
subcutaneous tissue around
the incision.

Mangram . Guideline for prevention of surgical

site infection, 1999. Infect Control Hosp Epidemiol 1999

Deep incisional surgical

site infections
< 30 days of procedure (or one
year in the case of implants)
are related to the procedure
involve deep soft tissues, such
as the fascia and muscles.

Mangram . Guideline for prevention of surgical

site infection, 1999. Infect Control Hosp Epidemiol 1999

ASEPSIS WOUND
SCORING SYSTEM

[ Wilson AP, Lancet 1986

Southampton wound
scoring system

[Bailey IS, BMJ 1992; 304: 469-71

Risk Factors
Surgical

factors
Patient-specific factors
local
systemic

Factors influencing SSIs

Patient Risk Factors
Local:
High

Systemic:

bacterial

load
Wound
hematoma
Necrotic tissue
Foreign body
Obesity

Advanced

age

Shock
Diabetes
Malnutrition
Alcoholism
Steroids
Chemotherapy
Immuno-

compromise

Factors influencing SSIs

Antibiotics
Prophylactic
Therapeutic

Factors influencing SSIs

Surgical Risk Factors
Type of procedure
Degree of contamination
Duration of operation
Urgency of operation
skin preparation
operating room environment
Antibiotic

prophylaxis
EWMA Journal 2005; 5(2): 11-15.

Berard F, Gandon J, Ann Surg 1964

Reduce hemoglobin A1c levels

to <7% before operation
Evidence

Class II data

References

Anderson DJ, Kaye KS, Classen D, et

al. Strategies to prevent surgical site
infections in acute care hospitals.
Infect Control Hosp Epidemiol 2008;

Smoking cessation 30 d
before operation
Evidence

Class II data

References

Anderson DJ, Kaye KS, Classen D, et

al. Strategies to prevent surgical site
infections in acute care hospitals.
Infect Control Hosp Epidemiol 2008

Remove hair only if it will interfere with

the operation; hair removal by clipping
immediately before the operation or
with depilatories; no pre- or
perioperative shaving of surgical
Evidence

Class I data

References

Kjnniksen I. Preoperative hair removal

a systematic literature review. AORN J 2002

Use an antiseptic surgical scrub

or alcohol-based hand antiseptic
for preoperative cleansing of the
Evidence
operative team members hands
Class II data
and forearms
References

Anderson DJ. Strategies to prevent

surgical site
infections in acute care hospitals.
Infect Control Hosp Epidemiol 2008;

Prepare the skin around the

operative site with an appropriate
antiseptic agent, including
preparations based on alcohol,
chlorhexidine, or iodine/iodophors

Evidence

Class II data

References

Anderson . Strategies to prevent

surgical site
infections in acute care hospitals.
Infect Control Hosp Epidemiol 2008;

Administer prophylactic antibiotics

for most clean-contaminated and
Evidence
contaminated
procedures,
and
Strong Class I data
selected clean procedures use
References
antibiotics appropriate for the
Springer R. The Surgical care
potential
pathogens
improvement
project-focusing on infection
control.Plast Surg Nurs 2007;

Administer prophylactic antibiotics within

1 h before incision (2 h for vancomycin
and
fluoroquinolones)
Evidence

Strong Class II data

References

Springer R. The Surgical care

improvement project-focusing on
infection control.Plast Surg Nurs
2007

Use higher dosages of

prophylactic antibiotics
for morbidly obese patients
Evidence

Limited Class II data

References

Springer R. The Surgical care

improvement project-focusing on
infection control.Plast Surg Nurs
2007

Carefully handle tissue, eradicate dead

space, and adhere to standard principles
of asepsis
Evidence

Class III

References

Anderson DJ. Strategies to prevent

surgical site infections in acute care
hospitals. Infect Control Hosp
Epidemiol 2008;

Redose prophylactic antibiotics with

short half-lives intraoperatively if
Evidence
operation is prolonged (for cefazolin if
Limited Class I, Class II data
operation is >3 h) or if there is
References
extensive blood loss

Scher K. Studies on the duration of

antibiotic administration for surgical
prophylaxis Am Surg 1997

Maintain intraoperative
normothermiac
Evidence

Class I; some contradictory Class II

data

References

Sessler DI, Akca O.

Nonpharmacological prevention of
surgical wound infections.
Clin Infect Dis 2002

Discontinue prophylactic
antibiotics
within
24
h
after
the
Evidence
procedure
(48 h for cardiac surgery
Class
I;
meta-analyses
&liver transplant
procedures)
support single
dose
regimens
for prophylaxis
discontinue
prophylactic
References ASHP Therapeutic guidelines on antimicrobial
antibiotics after skin closure
prophylaxis in surgery. Am J Health Syst Pharm 1999

Maintain serum glucose

levels <200 mg/dL on PO
Evidence

Class II data

References

Anderson DJ. Strategies to prevent

surgical site infections in acute care
hospitals. Infect Control Hosp
Epidemiol 2008

Monitor wound for the

development of SSI
Evidence
postoperative
days
1
and
2d
Class III data
References

Anderson DJ. Strategies to prevent

surgical site infections in acute care
hospitals. Infect Control Hosp
Epidemiol 2008

Treatment of SSI

opening the wound I&D .

For most patients who have had their
wounds opened and adequately
drained, antibiotic therapy is unnecessary.

Stevens DL. Prguidelines for the diagnosis and management of skin and soft-tissue
infections. Clin Infect Dis 2005actice

Treatment of SSI
o use antibiotics only when there are
significant systemic signs of infection
(temperature higher than
38.5Cor heart rate greater than 100
beats/min)
erythema extends more than 5 cm
from the incision.
Stevens DL. Prguidelines for the diagnosis and management of skin and
soft-tissue infections. Clin Infect Dis 2005actice

Sepsis
Sepsis:

Commonly called a
"blood stream infection.
The presence of bacteria
(bacteremia) or other infectious
organisms or their toxins in the
blood (septicemia) or in other
tissue of the body.

Sepsis
Sepsis may be associated with clinical
symptoms of systemic (bodywide)
illness, such as fever, chills, malaise ,
low blood pressure, and mental status
changes.
Sepsis can be a serious situation, a life
threatening disease calling for urgent
and comprehensive care.

Sepsis, Septic shock

Signs

of:
Increased C.O.
Altered O2 SATURATION.
Metabolic

acidosis (usually)
Can lead to ---Death.

Sepsis
Sepsis remains a major clinical
problem for 21st century
marginal improvement in the
mortality
antibiotics are cornerstone
10% improvement in mortality
Mac Arthur RD et al.Adequacy of early empiric antibiotic treatment in severe sepsis
experience from MONARCS trial . Clin Infect Dis 2004;38(2):284-88

Cytokines Release
TNF , IL1
IL6,10
Protease ,PG
PAF

Endothelial
injury

Tissue factor

Coagulopathy

Fibrin
clot

Inhibit activity
Protein C
Antithrombin III

Suppress
fibrinolysis

The aim
Sepsis is condition diagnosed on the bases
of clinical & laboratory parameters
increased level of inflammatory mediators
reflects global dysregulation of immune
response
Examine the latest evidence for the use of
immuno-modulating drugs obtained from
human clinical trials

immune response is multifaceted

Aim :

Eliminate
invading object

Maintain
homeostasis

Limit tissue
damage

Sepsis And host response

More

than adequate

or
Inadequate.

Inadequate Host response

Stimulation

by Levamisole
Pro inflammatory Cytokine
interferon y
Anti- prostaglandins
(immunosuppressive
mediators

IL-10
IL-

10 administration
improves survival
following endotoxin
challenge
Live candida - block IL-10improves survival

More than adequate host

response
Anti-inflammatory

cyotkines

like Interleukin 10
Agents to neutralise tumor
necrsois factor or interlekin -1

Severity assessment
PAC- initially
Ultra low frequency ossillations in
CO/global end diastolic vol -severity high
Lactate levels good severity predictor
Low exogenous clearance very early
predictor of mortality
C reactive protein high risk of organ
failure/ too slow to monitor

Management of Sepsis
Hemodynamic,

respiratory stability
Source control in sepsis
Early enteral feed/intensive insulin
therapy
stress ulcer prophylaxis, and deep
vein thrombosis
Daily hemodalysis better survival

Early goal-directed therapy (EGDT)

Oximetric central venous catheters

were placed to measure central
venous pressure
(CVP) & CvO2
500-mL aliquots of isotonic
crystalloid were given by bolus
infusion to achieve a central venous
pressure greater than 8 mm Hg.

Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment

of severe sepsis and septic shock. N Engl J Med 2001;

Early goal-directed therapy (EGDT)

Mean arterial pressure was

maintained at 65 mm Hg or higher
with vasopressors.
If the CvO2 saturation was still less
than 70%, blood was transfused to
a hematocritof 30.
If the CvO2 saturation was still less
than 70%, dobutamine was started.

Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment

of severe sepsis and septic shock. N Engl J Med 2001;

Early goal-directed therapy (EGDT)

Mortality was significantly lower

among patients randomized to
EGDT (48.2% versus
33.3%, P 5 .01).

Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment

of severe sepsis and septic shock. N Engl J Med 2001;

Sepsis
it

is complex process and the

goal of immune therapy is
identifying critical point of
response to modulate it

TNF
TNF is an important mediator
of sepsis
Serum level correlate with
outcome
Immunotherapy :
- Antibodies
- Blocking receptor
Calandra T et al.Prognostic values of tumor necrosis factor/cachectin,interlukin1,interferon-alpha and interferon gamma in the serum of patients with septic shock.
J Infec Dis 1990;161:982-87

Blockade of tumor necrosis

factor
Improves

outcome in E.
coli septicemia.
But increased mortality
with cecal ligation and
puncture.

TNF antibody
NEROCEPT :
reduction of mortality 1st 3
days - dose dependant
INTERSEPT :
-reduce progression of sepsis
- rapid resolution of shock

TNF antireciptor:
Recombinant receptor :
- dose dependant increase
in mortality
- deleterious effect in
human clinical trial
Fisher CJ et al.Treatment of septic shock with the tumot necrosis factor receptor.Fc
fusion protein .N Engl J Med 1996;334:1697-702

Steroids
Most widely known and used
immunotherapy
Blunt & potent anti-inflammatory
Action :

Prevent complement activation

inhibit nitrous oxide synthatase

Decrease proinflammatory cytokines

inhibit neutrophil aggregation

stabilise lysosomal membrane

1960-90S No advantage
1997 increase mortality with high dose
Beneficial for patient with adrenal insufficiency
Currently 2nd generation trials :
- low & physiological dose
- long duration
- vasopressor dependant pt
- no difference among corticotrophic
dependant or non dependant

Minneci PC et al Meta analysis:the effect of steroids on survival & shock during sepsis
depend on the dose. Ann Intern Med 2004;141:47-57

Inhibit thrombin and factor Xa

low during sepsis d/t
- impaired synthesis
- consumption by DIC
- degradation by elastase
Abraham E et al.Efficacy and safety of tifacogen in severe sepsis: randomised
controlled trial .JAMA 2003;290:238-47

APC action
Anti-inflammatory
Anticoagulant
inactivate Va,VIIa
Low level in sepsis
cytokine-induced
down-regulation of
thrombomodulin

APC

inhibit transcription
NF-kB reducing
proinflammatory
cytokines

Esmon CT. Inflammation & thrombosis : mutual regulation by protein C.

Immunologist 1998;6:84-89

APC

48hrs /reduces mortality

iv 24 ug/ kg/hr x 96hrs
Recombinant APC Dotrecogin alfa :
- Significant reduction of mortality
- faster resolution cardiovascular &
respiratory dysfunction
PROWESS ( protein c worldwide evaluation in severe sepsis)
multicentre study,2001

Vasopressor/ Inotropics
The Surviving Sepsis guidelines
recommended
dopamine or norepinephrine as first
line agents.
Vasopressin should be considered an
important adjunct vasopressor.
Epinephrine may be considered as a
second line agent.

Matthew C. Byrnes, MDa,b,*, GregJ. Beilman, MDa

INTENSIVE
GLUCOSEMANAGEMENT
Current

international recommendations
have been made to maintain blood
glucose levels lower than150 mg/dL.
Maintenance of blood glucose between
80 and 110 mg/dL may carry a
significant risk of hypoglycemia.

All of the mentioned immunotherapeutic

strategies worked in animal models of sepsis
but not always converted into patient
Comorbidity
Extreme ages
organ dysfunction
genetic polymorphism
site of infection

cautious multi-centre studies !

- differences resources
- availability of intensive care bed

Only APC has been shown to improve

outcome in septic patient
low steroid dose also worthy , should not
restricted to corticotrophin hyporesponsive patient
Sprung CL et al.Influence of alterations in foregoing life sustaining treatment
practices on a clinical sepsis trial.Critical Care Medicine 1997;25:383-7

most effective management of septic

patient remains recognition support of
organ dysfunction
antibiotics remain the cornerstone of
management

PERITONITIS

Classification
1.

Primary peritonitis

2.

Secondary peritonitis

3.

Tertiary peritonitis

Secondary peritonitis is the most

common form for surgeons

Intra-abdominal sepsis...

Diversion
Nutrition
Fluid & Electrolytes
ABG
Antibiotics

Diversion
Small Bowel : ileostomy
Large bowel : colostomy

More important than

antibiotics

Nutrition

Enteral or parenteral (TPN)

ANY QUESTION?