1. Seminar on Surgical infections
Prepared By: Dr. Atinkut Abesha
Moderator: Dr. Tilahun (G.Surgeon)
Date: 19/11/2014 E.C
1 Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
2. Outlines
2
Host defence mechanisms
Definition of Surgical Infections
Etiologies of Surgical infections
Classification of surgical infections
Surgical Site infections
Factors affecting SSIs
Clinical features of SSIs
Surgical infections other than SSIs
Prevention and treatments of surgical infections
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
3. Objectives
3
To know the defensive mechanisms of our body
to infections
To define what surgical infections mean
To describe different surgical infections
To know different factors affecting surgical
infections
To know how to prevent and treat surgical
infections
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
Surgical Infections: Prepared By:
Atinkut A. (Medical Intern)
4. Surgical Infections… Introduction
4
Host Defense Mechanisms
The host possesses several layers of endogenous
defense mechanisms that serve to prevent
microbial invasion, limit proliferation of microbes
within the host, and contain or eradicate invading
microbes.
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
5. Surgical Infections… Introduction
5
Host Defense Mechanisms:
Integumentary barrier
Mucosal surfaces (respiratory, gut, and
urogenital)
Colonization resistance
Defenses (phagocytosis, fibrinogen, iron
sequestration,)
Components that freely circulate throughout
the body
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
7. Surgical Infections… Introduction
7
Host Defense Mechanisms:
The magnitude of the response and eventual outcome
is generally related to several factors:
The initial number of microbes,
The rate of microbial proliferation
Microbial virulence
The potency of host defenses
Outcomes
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
eradicati
on
containm
ent
Regional
infection
Systemi
c
infection
8. Surgical Infections… Definition
8
Definition of Surgical Infections:
Infection: The presence of microorganisms in host
tissue or the bloodstream
Surgical infections:
Infections that develop following surgery or
traumatic injury
Infections that require surgical treatment for their
cure
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
13. I. Surgical Site Infections
13
Infections of the tissues, organs, or spaces
exposed by surgeons during performance of an
invasive procedure
Time of infection:
Within 30 days of surgery with out implant
Within one year of surgery with implant
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
14. I. Surgical wound…Classification
14
Based on the presumed magnitude of the
bacterial load at the time of surgery:
Clean wounds (class I)
Clean/contaminated wounds (class II)
Contaminated wounds (class III)
Dirty wounds (class IV)
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
16. I. Surgical wound…Classification
16
Wound class Rate of infection
with prophylaxis
(%)
Infection rate with
prophylaxis (%)
Clean (no viscus opened) 1-2 1-2
Clean contaminated (viscus
opened, minimal spillage )
3 6-9
Contaminated (open viscus
with spillage or
inflammatory disease )
6 13-20
Dirty (pus or perforation,
or incision through an
abscess)
7 40
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
17. I. Surgical Site Infections…Classification
17
Classification of Surgical Site infections: based on
depth/involved organ
Incisional (superficial, Deep)
Organ/space infections
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
18. I. Surgical Site Infections…Classification
18 Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
Classification of Surgical Site infections:
19. I. Surgical Site Infections…Classification
19
Classification of Surgical Site infections:
I. Major SSI;
Significant quantities of pus spontaneously
Needs procedure to drain it
Patients are systemically ill
Delayed return to home
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
20. I. Surgical Site Infections…Classification
20
Classification of Surgical Site infections:
II. Minor SSI
May discharge pus or infected serous fluid
But, are not associated with excessive discomfort,
systemic signs or delay in return to home
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
21. I. Surgical Site Infections…Risk factors
21
Risk factors for development of surgical site
infections:
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
Microbial
factors Local factors
22. I. Surgical Site Infections…Risk factors
Patient factors
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
22
Older age
Immunosuppression
Obesity
Diabetes mellitus
Chronic
inflammatory
process
Malnutrition
Smoking
Renal failure
Peripheral vascular
disease
Anemia
Radiation
Chronic skin disease
Carrier state
Recent operation
23. I. Surgical Site Infections…Risk factors
Local factors
Surgical Infections: Prepared By: Atinkut A. (Medical
Intern)
23
Open compared to laparoscopic surgery
Poor skin preparation
Contamination of instruments
Inadequate antibiotic prophylaxis
Prolonged procedure
Local tissue necrosis
Blood transfusion
Hypoxia, hypothermia
24. I. Surgical Site Infections…Risk factors
Surgical Infections: Prepared By: Atinkut A. (Medical
Intern)
24
Microbial factors
Prolonged hospitalization (leading to
nosocomial organisms)
Toxin secretion
Resistance to clearance (e.g., capsule
formation)
25. I. Surgical Site Infections…C/F
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Clinical features of Surgical infections:
Pain
Tenderness
Localized swelling
Redness
Hotness
Purulent discharge
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
26. I. Surgical Site Infections…Diagnosis
26
Diagnosis:
Purulent drainage
Isolation of organisms
Any one of sign and symptoms of infection
Diagnosed by operating surgeon/ found on
reoperation
Spontaneously dehisced fascia with at least one S
& S of inflammation
An abscess or other evidence of infection involving
the organ/space
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
27. I. Surgical Site Infections…Treatment
27
SSI treatment:
I. Treatments of Incisional SSIs:
Incision and drainage without the additional use of
antibiotics.
Antibiotic therapy is reserved for patients in whom
evidence of significant cellulitis is present
The open wound often is allowed to heal by
secondary intention
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
28. I. Surgical Site Infections…Treatment
28
SSI treatment:
II. Treatments of Organ/space SSIs:
Source control to resect or repair the diseased organ
Debridement of necrotic, infected tissue and debris
Administration of antimicrobial agents directed
against aerobes and anaerobes
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
29. I. Surgical Site Infections…Treatment
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SSI treatment:
II. Treatments of Organ/space SSIs:
If Patients in whom the above standard therapy
fails, typically develop one or more of the
following;
Intra-abdominal abscess
Leakage from a gastrointestinal anastomosis
leading to postoperative persistent peritonitis
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
30. I. Surgical Site Infections…Treatment
30
SSI treatment:
II. Treatments of Organ/space SSIs:
For Intra abdominal abscess:
Drained percutaneously
Surgical intervention is reserved for;
Those individuals who harbour multiple abscesses
Those with abscesses in proximity to vital structures
Those in whom an ongoing source of contamination
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
31. I. Surgical Site Infections…Prevention
31
SSI prevention: In general, control the risk factors
Preoperative measures:
Short preoperative hospital stay
Preoperative showering
Treat remote site infections
Optimize nutrition status
Optimize the glucose level
Stop smoking
Prophylactic antibiotic
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
32. I. Surgical Site Infections…Prevention
32
SSI prevention:
Intraoperative measures:
Follow aseptic technique
Avoid spillage
Complete debridement
Appropriate Surgical technique
Limit use of sutures/foreign bodies
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
33. I. Surgical Site Infections…Prevention
33
SSI prevention:
Postoperative measures:
Protect incision for 48-72 hours
Remove drains as soon as possible
Wearing protective sterile gloves during
examination
Early enteral nutrition
Tight glucose control
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
34. II. Surgical Infections other than SSIs
34
Infections that require surgical treatment for their
cure
Cellulitis
Erysipelas
Abscess
Pyomyositis
Necrotizing fasciitis
Ludwig’s Angina
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
35. II. Surgical Infections other than SSIs
1. Cellulitis 2. Erysipelas
35
Skin and subcutaneous
infections
Streptococcus and
staphylococcus
Usually unilateral
R/F;
Anything that causes break
in the skin
Inflammatory skin
condition
Skin (upper dermis) and
superficial lymphatic
infections
Streptococcus and
staphylococcus
Usually unilateral
R/F;
Anything that causes break
in the skin
Inflammatory skin condition
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
36. II. Surgical Infections other than SSIs
1. Cellulitis 2. Erysipelas
36
Edema from CVI/impared
lymphatic drainage
Immunosuppression
Indolent onset
Erythematous, edematous,
Hot skin
No clear demarcated
boarder
Edema from
CVI/impared lymphatic
drainage
Immunosuppression
Acute in onset
Erythematous,
edematous, Hot skin
Clear demarcated
boarder
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
37. II. Surgical Infections other than SSIs
37
Cellulitis/Erysipelas:
Treatment
Bed rest with legs elevated
Appropriate antibiotics
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
38. II. Surgical Infections other than SSIs
38
Cellulitis/Erysipelas:
Complications
Abscess
Necrotising fasciitis
Toxaemia and septicaemia
Precipitate ketoacidosis in a patient who has
diabetes mellitus
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
39. II. Surgical Infections other than SSIs
39
3. Abscess:
Localised collection of pus (dead and dying
neutrophils plus proteinaceous exudate).
Trauma, Immunocompromised conditions, IV drug
abusers are often affected
Pyogenic abscess
Pyaemic abscess
Cold abscess
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
40. II. Surgical Infections other than SSIs
40
I. Pyogenic abscess:
Intense inflammation that tend to stimulate acute
inflammation which is caused by bacteria
Staphylococcal infections
Route of infections;
External wound
Haematogenous
Previous untreated cellulitis
Encircled by fibrin products
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
41. II. Surgical Infections other than SSIs
41
I. Pyogenic abscess:
C/F:
Hotness
Redness
Swelling
Loss of function
Throbbing pain
Fluctuant mass
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
42. II. Surgical Infections other than SSIs
42
I. Pyogenic abscess
Treatments:
Incision and drainage
Then, appropriate antibiotics for 5-7 days
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
43. II. Surgical Infections other than SSIs
43
I. Pyogenic abscess
Pyomyositis:
Localised area of suppuration within striated
muscle
Quadriceps, gluteus, shoulder and upper arm
muscle are affected
Pain over the part oedema, fever, tenderness,
induration and spasm of the affected muscle
Renal failure follows soon
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
44. II. Surgical Infections other than SSIs
44
I. Pyogenic abscess
Pyomyositis: Stages
Stage of cellulitis
Stage of Abscess
Stage of sepsis
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
45. II. Surgical Infections other than SSIs
45
I. Pyogenic abscess
Pyomyositis treatment
Early diagnosis and early aggressive treatment
Antibiotics
Exploration-for diagnosis and as a treatment
Wide excision of muscles and compartmental
excision till viable tissues are visible
Surgical Infections: Prepared By:
Atinkut A. (Medical Intern)
46. II. Surgical Infections other than SSIs
46
II. Pyaemic abscess:
Occurs due to circulation of pyaemic emboli in
the blood
Due to pus-producing organisms in the
circulation
Commonly occurs in diabetics and patients
receiving chemotherapy and radiotherapy
Characterised by following features; multiple,
deep-seated, minimal tenderness, Local rise of
temperature is not present
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
47. II. Surgical Infections other than SSIs
47
II. Pyaemic abscess:
Treatments:
Multiple incisions over the abscess site and
drainage
Then, appropriate antibiotics for 5-7 days
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
48. II. Surgical Infections other than SSIs
48
III. Cold abscess:
Lacks the intense inflammation usually associated
with infection that do not tend to stimulate acute
inflammation
Has no signs of inflammation
Causes are TB, Leprosy, Actinomycosis
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
49. II. Surgical Infections other than SSIs
49
III. Cold abscess:
Treatments
Anti tuberculosis regimen/leprosy
Excision
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
50. II. Surgical Infections other than SSIs
50
4. Necrotizing fasciitis
It is a spreading, destructive, invasive infection of
skin and soft tissues including deep fascia with
relative sparing of muscle
Common sites: lower extremities, genitalia, groin,
lower abdomen
Risk factors: DM, Malnutrition, obesity,
immunosuppression conditions
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
51. II. Surgical Infections other than SSIs
51
4. Necrotizing fasciitis
Type I necrotising fasciitis: Polymicrobial
Type II necrotising fasciitis: Monomicrobial
Surgical Infections: Prepared By:
Atinkut A. (Medical Intern)
52. II. Surgical Infections other than SSIs
52
4. Necrotizing fasciitis
Clinical Features:
Sudden pain in the affected area
Gross swelling of the limbs
Redness
erythematous
Skin necrosis and ulceration
High degree fever, jaundice, renal failure can
occur soon in untreated cases
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
53. II. Surgical Infections other than SSIs
53
4. Necrotizing fasciitis
Treatments:
Early, aggressive treatment includes supportive
and surgical treatment
Hospitalisation
Adequate hydration
broad spectrum antibiotics
wide excision, generous debridement followed by
skin grafting, a few days or weeks later
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
54. II. Surgical Infections other than SSIs
54
5. Ludwig’s Angina
Cellulitis of submental and submandibular regions
combined with inflammatory edema of the mouth.
Causative agents: streptococcal and anerobic
microbes
Risk factors: Caries tooth, Cancer of the oral
cavity, Calculi in the submandibular gland,
Chemotherapy, Cachexia and Chronic disease (6
Cs)
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
55. II. Surgical Infections other than SSIs
55
5. Ludwig’s Angina
Clinical Features:
Diffuse swelling in the submandibular and
submental region
Edema of the floor of the mouth
High grade fever with toxicity
Putrid halitosis
Dysphagia/odynophagia/drooling
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
56. II. Surgical Infections other than SSIs
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5. Ludwig’s Angina
Complication
Compromise airway
Septicemia
Surgical Infections: Prepared By:
Atinkut A. (Medical Intern)
57. II. Surgical Infections other than SSIs
57
5. Ludwig’s Angina
Treatments:
Rest
Hospitalisation
Appropriate antibiotics
IV fluids to correct dehydration
Tube feeding
Surgical intervention
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
58. References
58
Schwartz's Principles of Surgery 11th edition
Bailey & Loves Short Practice of Surgery 27th
edition
Manipal Manual Of Surgery 4th Edition
Uptodate
Surgical Infections: Prepared By: Atinkut A. (Medical Intern)
Site-specific defenses that function at the tissue level, as well as components that freely circulate throughout the body in both blood and lymph
Host barrier cells may secrete substances that
limit microbial proliferation or prevent invasion
Patient factors
or who concurrently manifest a SIRS.
Effective source
control and antibiotic therapy is associated with low failure
rates and a mortality rate of approximately 5% to 6%; inability
to control the source of infection is associated with mortality
greater than 40%.
The
necessity of antimicrobial agent therapy and precise guidelines
that dictate duration of catheter drainage have not been established.
A short course (3 to 5 days) of antibiotics that possess
aerobic and anaerobic activity seems reasonable so long as the
patient has good clinical response to therapy, and most practitioners
leave the drainage catheter in situ until it is clear that
cavity collapse has occurred, output is less than 10 to 20 mL/d,
no evidence of an ongoing source of contamination is present,
and the patient’s clinical condition has improved
Repeat only during long operations or if there is excessive
blood loss
Lymphangitis
due to group A /3-haemolytic
Streptococcii
SPECIFIC FEATURES OF TYPE II
NECROTISING FASCIITIS
• Caused by Streptococcus pyogenes
• Occur in young healthy people
• Minor abrasions, laceration may be a precipitating factor
• Severe systemic illness with multiorgan failureStreptococcal
toxic shock syndrome
NECROTISING FASCIITIS I-RISK FACTORS
• Diabetes mellitus, malnutrition
• Obesity, corticosteroids
• Immune deficiency