Surgical Infections

Surgical Infections

Wound infection- invasion of organism through tissue

following breakdown of local and systemic defenses

Surgical infections may arise in the surgical wound

itself or in other systems in the patient.
 Kochspostulates
Infective organisms must be found in considerable no. in
septic foci
Possible to culture in pure form
It should be able to produce similar lesion when injected in
another host
 Protective mechanism
Mechanical barrier
Chemical low gastric ph
Humoral- antibodies, complement, opsonins
Cellular- phagocytes, macrophages, pmn and killer cells
 Some definitions
Colonization:
presence of bacteria in a wound with no signs or symptoms of
systemic inflammation . usually bacterial count less than 10*5cfu/ml
Contamination:
Transient exposure of a wound to bacteria.
Varying concentration of bacteria possible.
Time of exposure less than 6 hours.

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

Metabolic- malnutrition, obesity, diabetes, ureamia, jaundice

Disseminated disease- cancer, AIDS
Iatrogenic- radiotherapy, chemotherapy, steroids
 Risk factors for increased wound
infection
Malnutriton- obesity,weight loss
Metabolic diseases- diabetes, ureamia, jaundice
Immunosupression-cancer, AIDS, steroids,
chemotherapy,radiotherapy
Colonisation and translocation in G.I. tract
Poor perfusion- shock
Foreign body material
Poor surgical technique
 Physiology
Suspended Enteral feeding during perioperative period with
underlying disease
Colonisation of gram negative bacilli in gut
Translocation to mesenteric lymph nodes
Release of endotoxins,
Activation of macrophages and cytokines release
Sirs and MODS
 SIRS
SIRS is the body's response to infected wound

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

Sepsis may be associated with MODS

 Surgical Infections
Two main types

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

an infection that is present up to 30 days after a

surgical procedure if no implants are placed, and up to
one year if an implantable device was placed in the
patient

The majority of SSIs will occur during the first 2-3

weeks after surgery
 Types
1. Major- significant pus or needs secondary procedure to drain
it
Tachycardia, pyrexia or raised cbc

2. Minor- may discharge pus but not associated with excessive

discomfort , systemic signs or delayed return
Asepsis scoring system for severity of wound infection
 Types of Surgical Site Infections

According to the tissue involved:

1. Superficial
2. Deep incisional
3. Organ/space
 Superficial incisional SSI :

Infection occurs within 30 days after the operative procedure

and
involves only skin and subcutaneous tissue of the incision
and

patient has at least one of the following:

a. purulent drainage from the superficial incision.
b. organisms isolated from an aseptically obtained culture of fluid or tissue from
the superficial incision.
c. at least one of the following signs or symptoms of infection: pain or
tenderness, localized swelling, redness, or heat, and superficial incision are
deliberately opened by surgeon, and are culture-positive or not cultured. A
culture-negative finding does not meet this criterion.
d. diagnosis of superficial incisional SSI by the surgeon or attending physician.
A deep incisional SSI must meet one of the following
criteria:

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
and
involves deep soft tissues (e.g., fascial and muscle layers) of the incision
and
patient has at least one of the following:
a. purulent drainage from the deep incision but not from the organ/space component
of the surgical site
b. a deep incision spontaneously dehisces or is deliberately opened by a surgeon and is
culture-positive or not cultured and the patient has at least one of the following
signs or symptoms: fever (>38C), or localized pain or tenderness. A culture-
negative finding does not meet this criterion.
c. an abscess or other evidence of infection involving the deep incision is found on
direct examination, during reoperation, or by histopathologic or radiologic
examination
d. diagnosis of a deep incisional SSI by a surgeon or attending physician.
 An organ/space SSI must meet one of the following
criteria:

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

2. Operating theater environment

3. Hospital personnel (doctors/nurses/staff)

4. Seeding of the operative site from distant focus of infection (prosthetic

device, implants)
 Pathogenesis of SSI
Relationship equation

Dose of bacterial contamination x Virulence

Resistance of host

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

Wound class Definition Example Infection

rate (%)
Clean Nontraumatic, elective Mastectomy 2%
surgery. GI tract, Vascular
respiratory tract, GU tract Hernias
not entered
Clean- Respiratory, GI, GU tract Gastrectomy < 10%
contaminated entered with minimal Hysterectomy
contamination
Contaminated Open, fresh, traumatic Rupture appy 20%
wounds, uncontrolled Emergent
spillage, minor break in bowel resect.
sterile technique
Dirty Open, traumatic, dirty Intestinal 28-70%
wounds; traumatic fistula
perforation of hollow resection
viscus, frank pus in the
field
 Determinants of the infection
Every surgical site is contaminated by bacteria at the end of the
procedure, few become clinically infected.
Important determinants lead to either uneventful wound healing or
SSI.

1. Inoculums of the bacteria

2. Virulence of the bacteria
3. Integrity of host defenses (Innate and acquired )
4. Effects of microenvironment
 1. Inoculum of the bacteria

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

The more virulence the bacteria, the greater

probability of infection
Coagulase positive staph
Virulent strain of perfiringens and group A streptococi
E coli
Bacteroids
This factor can not easily be controlled by preventive strategies because it
is intrinsic to the procedural site and the type of bacteria that already
colonize the patient
 3. Effects of microenvironment

The following factors in the microenviroment of the wound

predispose to SSI
Necrotic tissue
Hb at the surgical site
FB, drains
Dead space with in the surgical site
Surgical techniques
Vascularity and health of tissues
Presence of dead and foreign body
Presence of antibiotics during decisive
 4. Integrity of host defenses

Innate host defense deficiency

Acquired host defense deficiency
Shock and hypoxia
Transfusion
Chronic illness
Hypoalbuminaemia
Malnutrition
Hypothermia
Hyperglycemia
Corticosteroids
Obesity
Nicotine use
chemotherapy
 Prevention of SSI
1. Preoperative planning
2. Intra operative technique
3. Preventive antibiotic therapy
4. Enhancement of host defense
 1. Preoperative planning
Control preexisting infection of patient

Postpone the operation if open skin wound or hand infection of surgeon

present

Decrease preoperative hospitalization period

Shower and scrub the surgical site with antiseptic soap the evening prior
to operation

Clipping the hair from surgical site before the operation

 2. Intra operative technique
Skin preparation Avoid dead space

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