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Surgery: Surgical Infections

Lecturer: Dr. Acuna
September 1, 2015
2. Respiratory Tract
HOST DEFENSES cilia
mucus
1. Skin macrophages (few in the upper RT)
resident microflora normal flora
Staphylococcus epidermidis alpha and beta hemolytic strep
Propionibacteria anaerobes
Corynebacteria staph
shedding of skin cells diptheroids - commensals
chemicals from sebaceous gland neisseria (non-meningitidis)
oily skin hemophilus
Beta hemolytic step mycoplasma
80% of damage from scratching; remaining pneumococcus
20% plucking hair, shaving, tight clothing
insect bites 3. Stomach
acidic environment kills most bacteria, except
for H. pylori (highly resistant to acid
Skin abscess use of proton pump inhibitors (PPIs)
-> acid reduction -> makes stomach
board exam question: What is the first susceptible for bacterial infection
question you will ask for a patient highest bacterial count after eating
complaining of skin abscess? bacteria from oral cavity plus bacteria from
A: Do you have history of chronic itching? food
bacteria almost undetectable after digestion
make wide incision (as wide as as the (2-3 hours after eating)
lesion) incisional drainage: never
squeeze

incisional drainage: never squeeze

4. Small bowel
aected area to evacuate fluid; spread of
streptococci - gram (+)
infection may go downward
lactobacilli - gram (-)
non-immunocompromised
bacteroides - anaerobes
treatment: incisional drainage only
these are more common in lower GI
immunocompromised
all of these are transients, normal flora
acquired

congenitally immunocompromised
5. Colon - polymicrobial
extremes of age
anaerobes (95-99%)
bacteroides antibiotics for
steroids
anaerobes
cancer therapy: chemo, radiation
bifidibacteria
tx: incisional drainage + antibiotic
clostrida
metronidazole,
S. aureus = non-foul smelling;
eubacterium
lactobacillus clindamycin
E. coli = fouls smelling
peptostreptococcus
aerobes
E. coli
Carbunle
enterobacteria
crater-like, cluster of boils enterococci
polymicrobial: Staph and Strep candida
if with MRSA, tx: linezolin bacterial translocation to blood vessels is
and necessary debridement of wound termed bacteremia.

Cellulitis
streptococcal = thin and watery
treatment: ??
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Microbial infection
Sterile areas
areas without the presence of bacteria

biliary and pancreatic

lower respiratory
urogenital tract

*note: sepsis in these areas are very critical

cases because they are supposed to be strictly
sterile.

introduction of micro-organismis may be due to

the following conditions: Consists of:
malignancy Eradication
inflammation competent immune system
calculi Containment
foreign body failure to eradicate
collection of pus/abscess formation
introduction of micro-organisms from external Locoregional infection
sources: failed containment
catheters System infection
IFC bacteremia, pumasok sa dugo
ET not yet sepsis
Comments, in-lecture
Reference value for blood sugar = 60-100
Defenses in body cavities However, wounds will still heal well if level is at 250 or
less. Therefore, diabetes by itself is not enough basis
whether wounds will heal well or not.
lactoferrin and transferrin
iron is an important microbial growth
factor
stomata in diaphargm RELEVANT
omentum DEFINITIONS:
macrophages, complement,
immunoglobulin, PMNs SIRS
fibrin - langib ng sugat may come from
the ff: (2 out of 4)
For open wounds, do not remove fibrin; however, trauma,
if fibrin deposits are found in the lungs, do remove aspiration,
them as these accumulations may impede pancreatitis,
respiratory function. burn

Infection: documented
presence of
microorganism

sepsis: infection + SIRS

(a negative culture does not mean (-) sepsis)
severe sepsis: +organ dysfunction
septic shock: +organ failure

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INFECTIONS OF SIGNIFICANCE IN SURGICAL
I. RT, GU, GI entered
PATIENTS
CLEAN uninfected, no
Surgical site infections (SSI)

contamination
Intra-abdominal infection

1-2% infection rate closed primarily

Organ-specific

Skin and soft tissue infection

examples:

Post-op nosocomia infection
MRM

thyroid
A. Surfical site infection (SSI)
hernia
vascular
infection of tissues, organs and spaces
splenectomy
exposed by surgeon during operation

0-30 days (occurence)

1 year if mesh, vascular graft, joint II. RT, GU, GI entered

prosthesis, heart valves
CLEAN controlled
within 5 days (usual onset)
CONTAMINATED contaminants
severe if within 24 hours d/t Strep or closed primarily
Clostridias
2-10 infection rate examples
chole
uncomplicated AA
gastric
Incisional Organ / Space small bowel
colon
Superficial Body cavity involved trachea
skin and SQ only bronchii
fascia uninvolved
III. open, fresh accidental
Deep Peritonitis CONTAMINATED wounds
fascia involved major breaks in sterile
3-13% infection rate technique
gross spillage from
GIT
examples
Patient factors Local factors
AA
Chole with bile
older age open sx vs spillage
immunosuppression laporoscopy
diverticulitis
obesity, malnutrition poor skin prep
rectal surgery
DM contaminated
penetrating
chronic inflamm instruments wounds
anemia poor prophylactic
smoking antibiotic IV. old, traumatic wounds
(no. 1 volunatry prolonged DIRTY existing infection or
cause of CA) procedure perforation
renal failure local tissue necrosis 3-13% infection rate organism present
peripheral vascular blood transfusion before surgery
disease hypothermia, examples:
radiation and and hypoxemia
abscess
previous sx
perforated viscus
peritonitis,
Mga puwede mong sisihin sa (+) pre-op cultures
pasyente :))
Surgical wound classes
Class I and II = close primarily

Class III, IV = primary closure assoc with 25-50 infection rate

secondary intention (secondary wound closure

tertiary intention (delayed primary wound closure)

Microbial factors primary closure with drains

prolonged hospitalization

toxin secretion

resistance to clearance (capsule)

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B. Intra-abdominal 3. Tertiary peritonitis
in immuno-compromised patients
1. Primary peritonitis reccurent type
sources: polymicrobial
hematogenous S. epidermidis
direct Candida
innoculation Enterococcus
medical Pseudomonas
management >50% mortality rate even with antibiotics
2-3 weeks
antibiotic C. Organ specific
remove catheter
recurrent 1. Liver abscess
CT scan - 10cm or more
2. Seconday peritonitis non-septated
secondary to amoebic
another intra-abdominal case septated
appendicitis bacterial
meckels diverticulitis most likely E. coli
diverticulitis (anaerobe)
treatment is surgical (source control)
mortality rate 5-6%
failure to achieve source control increases
mortality rate to >40%
priorities:
resuscitation + antibiotic

2. Pancreatic abscess
polymicrobial
multibacterial - gram (-) aerobe

D. Soft tissue

1. Necrotizing fasciitis /
Fourniers disease
anaerobes
polymicrobial

source control

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2. Cellulitis
Anaerobes
streptococcus
3. Lymphangitis
Gram (+) Anaerobes
spreading cellulitis
streptococcus Clostridium difificile
Clostridium perfingens
C. tetani, C. septicum
Peptostreptococcus spp.

Gram (-) Anaerobes

Bacteroides fragilis
Fusobacterium spp.

Virus
E. Post-op nosocomial infections
Cytomegalovirus
Review and memorize this table daw: Epstein-Barr virus
Hepatitis A, B, C
Herpes Simplex virus
Human immunodefficiency virus
Varicella zoster virus

Fungi

MICROBIOLOGY OF INFECTIOUS AGENTS Aspergillus fumingatus,

A. niger, A. terreus, A. flavus
Blastomyces dermatitidis
Gram (+) Cocci Candida albicans
Candida glabrata, C. paropsilosis, C. krusei
Staphylococcus aureus Coccidiodes immitis
Staphylococcus epidermidis
Cryptococcus neoformans
Streptococcus pyrogens Histoplasma capsulatum
Streptococcus pneumoniae Mucor/Rhizopus

Enterococcus faecum
Enterococcus fecalis
Other Bacteria
Gram (-) Bacilli Mycobacterium avium-intercellulare
(*KEEPS*)
Mycobacterium tuberculosis
Escherichia coli * (old wound with multiple fistula)
Haemophilus influenzae Nocardia asteroides
Klebsiella pneumoniae * (black lesions which are highly contagious)
Proteus mirabilis
Enterobacter cloacae, aerogenes * Legionella pneumophilia
Serratia marcescens *
Acinetobacter calcoaceticus Listeria monocytogenes
Citrobacter fruendii
Pseudomonas aeruginosa *
Xanthomas maltophilia BAHAGHARI 15
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PREVENTION OF SURGICAL INFECTIONS

A. Sepsis and antisepsis

B. Prophylactic antibiotics
broad spectrum
given 30 minutes to one hour prior to incision
antibiotic should reach subcutaneous
tissue before cutting
repeat dosing for prolonged surgery (>4 hours) 1.Principles of antibiotic prophylaxis
discontinued within 24 hours select antibiotic for common bacteria on
surgical site
C. Shaving- done immediately prior to incision give antibiotics 30 mins before surgery
risk for micro-wounds redose antibiotics for prolonged operations
discontinue after 24 hours
D. Surgical scrub - routinely done
2. Empirical therapy
E. Prepping Progression from prophylactic therapy
7.5% betadine first -> 10% betadine no microbiologic data yet (C&S)
antiseptic effect is for 4 hours only gram stain available
short course of 3-5 days
TREATMENT OF SURGICAL INFECTIONS indications
intraoperative findings (Class I to III)
A. Organized approach to therapy includes the ff: critically ill patients
1. rapid rescuscitation sepsis, severe sepsis, septic shock
2. antibiotics discontinued after clinical improvement
3. source control
incision and drainage 3. Therapy of established infection
wound debridement C & S available
abdominal exploration (7 days before de-escalation therapy
air dissapears post op) narrower spectrum but more precise
amputation MONOMICROBIAL
most nosocomial infections
B. Appropriate antimicrobial use DURATION OF TREATMENT (monomicrobial)
Knowledge of microflora in area involved
lower GI = Anaerobes > Gram(-) >Gram (+) UTI 3-5 days
Knowledge of antimicrobial spectrum of activity
Monotherapy = Cefotixin or Cefotetan pneumonia 7-10 days
Polytherapy
Metronidazole + Cefuroxime bacteremia 7-14 days
Metronidazole + Aminoglycoside
Clindamycin + Quinolone endocarditis, 6-12 weeks
osteomyelitis, prosthetic
infections
Other applications POLYMICROBIAL
treated primarily by debridement
Diabetic foot = polymicrobial Culture and sensitivity less important
monotherapy: sultamicillin clinical course dictates if antibiotics need to
polytherapy: quinolone + clindamycin
be changed or not after C & S are out
Skin and soft tissue infection = gram (+)
monotherapy: Sultamicilin Impact of antibiotic misuse include:
polytherapy: quinolone + clindamycin increased health care cost, drug reactions and
toxicity, development of new infections like
Bowel perforation
Clostridium difficile colitis, and multi-drug resistance
if it smells like poop, chances are it is poop
Give clindamycin in nosocomial pathogens

Cefoxitin = 2nd gen cyclosporin with anti-anaerobic activity; used

for GI infections, protocol worldwide BAHAGHARI 15
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