SURGICAL INFECTIONS

Under supervision of :
Dr. MOHAMMED AL-AKEELY

infection
Invasion of the body by pathogenic
microorganisms and reaction of
the host to organisms and their
toxins

A surgical infection is an
infection which requires surgical
treatment and has developed
befor, or as a complication of
surgical treatment.

 could

be life threatening

Accounts

patients

for 1/3 of surgical

Increased

cost to healthcare

Some imp defin.

Bacteremia: bacteria in blood

SIRS: systemic inflammatory response
syndrome (fever, tachycardia,
tachypnea, leukocytosis)
Sepsis: documented infection & SIRAS
Septic shock: sepsis & hypotension
refractory to fluid resuscitation

Principles of surgical
treatment

Debridement- necrotic, injured, dead

tissue

Drainage- abscess, infected fluid

Removal- infection source, foreign body
Supportive measures:

immobilization
elevation
antibiotics

Common organisms
Gram positive bacteria:
Streptococci
Staphylococci
Clostridia
Gram negative bacteria:
Pseudomonas
E. coli
Bacteroid fragilis

Streptococcal infections

1.
2.
3.
4.

Cellulitis
Lymphangitis
Lymphadenitis
Necrotizing faciitis

cellulitis

severe inflammation of dermal and subcutaneous layers of

the skin.

caused by normal skin flora(group A strept /staph)or by

exogenous bacteria.

the bacteria can spread rapidly, entering the lymph nodes

and the bloodstream and spreading throughout the body.

In rare cases, the infection can spread to the deep layer of

tissue (Necrotizing faciitis).

often occurs in broken skin.

cellulitis

Signs & symptoms: affected area is red, hot, and

tender with vague borders.

Most common sites : Face, hand and lower extremities.

RF: old age & immunodeficiency.

Diagnosis: clinically.

TX:
1- resting, elevation of the affected limb, debridement.
2- ampicillin/amoxicillin in moderate (suspected strept) +
flucloxacillin or dicloxacillin for mild (staph)

cellulitis

Erysipelas
Erysipelas is the term used for a

more superficial infection of the

dermis and upper subcutaneous
layer that presents clinically with
raised surface and well defined
edge.

Erysipelas and cellulitis often

coexist, so it is often difficult to
make a distinction between the two.

Erysipelas

Lymphangitis

Lymphangitis is an inflammation of
the lymphatic channels that occurs as
a result of infection at a site distal to
the channel.

Streptococcus pyogenes.

Signs and symptoms: deep

reddening of the skin, warmth, with
moderate pain and swelling.
Lymphadenitis, chills and a high fever
along. ( appears as red streak).

Lymphangitis

Tx:

1-elevate and immobilize affected areas

to reduce swelling, pain, and the
spread of infection.
2- antibiotic.

Lymphangitis

LYMPHADENITIS

Lymphadenitis is an infection of the

lymph nodes.
Lymphadenitis may occur after skin
infections or other bacterial infections,
particularly those due to streptococcus or
staphylococcus.
Swollen, tender, or hard lymph nodes
Red, tender skin over lymph node
Lymph nodes may feel rubbery if an
abscess has formed.

LYMPHADENITIS

Treatment may include:

Antibiotics to treat any underlying infection
Analgesics (pain killers) to control pain
Anti-inflammatory medications to reduce
inflammation and swelling
Cool compresses to reduce inflammation
and pain
Surgery may be needed to drain any
abscess.

LYMPHADENITIS

Necrotizing fasciitis
(flesh-eating disease)

Infection and necrosis of the deeper layers of skin and

subcutaneous tissues.

2 types: l:polymicrobial
ll: monomicrobial (mostly group A strept)

Signs and symptoms: The infection begins locally,

at a site of trauma>>intense pain>> then tissue
becomes swollen (hrs.)

Common sites: abdominal wall, perineum, and limbs.

Diagnosis: visual examination & microscopic

evaluation of tissue samples.

Necrotizing fasciitis

RF: diabetes, abdominal surgery, drug addict

and trauma.

Tx:

1-Early medical treatment (combination of

intravenous antibiotics including penicillin,
vancomycin, and clindamycin)
2-Cultures are taken to determine appropriate
antibiotic
3-aggressive surgical debridement ( no
definitive boundries!!)

High mortality rate (75%) if left

Necrotizing fasciitis

Staphylococcal
Infections

Abscess: is a collection of pus (dead

neutrophils) that has accumulated in a cavity

formed by the tissue

It is a defensive reaction of the tissue to

prevent the spread of infectious materials to
other parts of the body

As Staphylococcus aureus bacteria is a

common cause, an anti-staphylococcus
antibiotic such as flucloxacillin or dicloxacillin
is used
Incision and drainage is a common
surgical intervention in case of abscess

Staphylococcal
Infections
1.

Furuncle- infection of one hair follicle /

sweat glands

Carbuncle- extension of furuncle into subcut.

Tissue with possible formation of abscess.
usually more than one furuncle
common in diabetic patient
common sites- back, back of neck
Treatment: drainage, antibiotics, control
diabetes

2.

Staphylococcal
Infections

Clostridial infections

1.
2.
3.

Gas gangrene
Tetanus
Pseudomembranous colitis

GAS GANGRENE

is a bacterial infection that produces gas in

gangrenous tissues usually caused by Clostridium
perfrengins bacteria.

It is a medical emergency (Progression to toxemia

and shock is often very rapid)

Large wounds contaminated by soil.

It results in rapid myonecrosis, swelling, seropurulent

discharge, foul smelling wound, crepitus in
subcutaneous tissue.

GAS GANGRENE

X-ray: gas in muscle and under skin.

Tx:
1-Wound exposure, debridement ,
drainage.
2-Penicillin, clindamycin, metronidazole
3-Hyperbaric oxygen chamber

GAS GANGRENE

TETANUS
Cl.

Tetani, produce neurotoxin

Penetrating wound ( rusty nail, thorn )
Incubation period: 7-10 days
Usually wound healed when symptoms appear
Trismus- first symptom, stiffness in neck & back
Anxious look with mouth drawn up ( risus sardonicus)
Progressive dysphasia, dysphagia, dyspnea &
tonic convulsion
Death by exhaustion, aspiration or asphyxiation

TETANUS
Treatment:
wound debridement
Muscle relaxants, penicillin
ventilatory support
Prophylaxis:
vaccination by HTIG & T toxoid in tetanus
prone wound in patient with unknown or
incomplete history of immunization.
If it is more than 5 years since last dose of
tetanus immunization give only T toxoid.

PSEUDOMEMBRANOUS COLITIS

Superinfection in patients in long term oral

antibiotic therapy
Cl. Difficile
Watery diarrhea, abdominal pain, fever
Diagnosis needs Sigmoidoscopy, stool- culture
and toxin assay

Treatment :

stop offending antibiotic

oral vancomycin/ metronidazole
rehydration, isolate patient

Pseudomonas

Opportunestic bacteria that may cause surface

infections, but may also cause serious and
lethal infection.

Enter the body through minor skin abrasion,

ventilator tubes, urinary catheters and IV lines
>>> therefore it is common in ICU.

Can cause septecimia (particularly in burn

wounds)

Tx: aminoglycosides, piperacillin, ceftazidine.

E. coli

Normal intestinal flora, facultative

anearobes.

May cause circulatory collapse (due to

endotoxin), wound infections, meningitis,
endocarditis, abdominal abscess & UTI.

Tx:

ampicillin, aminoglycosides,
cephalosporine.

Bacteroides fragilis

1.

Normal flora of mouth and colon, anearobic.

Produce foul smelling pus, gas in surrounding
tissues & necrosis.
Responsible for intraabdominal & gyne.
infection.
Causes spiking fever, jaundice & leukocytosis.
Tx:
Surgical drainage, excision.

2.

Clindamycin, metronidazole.

Hospital aquired
infections
The most common is UTI
The most common causing
death is pneumonia.

Surgical site infection

(SSI)
38% of all surgical infections
Infection within 30 days of operation
Classification:

Superficial:

Superficial SSIinfection in subcutaneous plane

(47%)

Deep:

Subfascial SSI- muscle plane (23%)

Organ/ space SSI- intra-abdominal, other spaces (30%)

Staph. aureus- most common organism

E coli, Entercoccus ,other Entetobacteriaceae- deep
infections
B fragilis intrabd. abscess

Surgical site infection

(SSI)
Risk factors: age, malnutrition,
obesity, immunocompromised, poor
surg. tech, prolonged surgery, preop.
shaving and type of surgery.
Diagnosis:

Sup.SSI- erythema, oedema, discharge and pain

Deep infections- no local signs, fever, pain,
hypotension.
need
investigations.

Treatment: surgical / radiological intervention.

Surgical site infection

(SSI)
Intra-abdominal infections
Generalized
Localized
Prevention- good tech., avoid bowel
injury, good anastomosis.
Diagnosis- History, exam.,
investigations CT scan.
Treatment- surgery/ intervention
Antibiotics (aerobe+ anaerobe)

UTI
UTI are usually consequences of
foley cathetar.
The most common symptoms of a
bladder infection are burning with
urination (dysuria), frequency of
urination and an urge to urinate.
may also present with flank pain
and a fever.

UTI
Diagnostic test:

-urinalysis (nitrate, estrase)

-culture

-urine microscopy (WBC>10)

The common org. is:

- E. coli, klebsiella, enterococcus

& staph. aureus

TREATMENT
Ab.with gram (-) spectrum
-sulphamethoxasole
-trimethoprim
-gentamycin
-ceprofloxacin
Check culture &sensitivity

pneumonia

Rout of infection:
-gross aspiration during anesthesia
or intubation. Pathogen includes
anaerobic organism & gram(-)
bacilli.
- Atelectasis: the collapsed lung may
become secondarily infected
-contiguous spread from another site.

pneumonia
Sing & symptoms :
People with pneumonia often have one or more
of these symptoms: Fever, productive cough,
shortness of breath, hypoxia and chest pain.

Chest x-ray & sputum culture are important to

confirm the diagnose.

treatment
Hospital acquired pneumonia
generally treated by cefuroxime,
ceftriaxone for the usual
pathogen( gram(-), s.aureus ,
strept.pn, & H. influenzae) +
treatment of other pathogen.
if there is recent Hx of abd.surg
the infectious org. is anaerobes
we should add clindamycin

If the pt. is comatose or has head

trauma, DM, or renal failure the org.
usually is s.aureus & there is risk of
MRSA
we add vancomycin

If the pt. take high dose of

glucocorticoides the org. usually is
legionella
we add macrolide
(azithromycin)

If the pt. has malnutrition, structural lung

disease, glucocorticoid therapy the org.
usually is pseudomonas.a

Also if the pt. has Hx of neuro.surg. ,head

trauma, ARDS, aspiration the org. usually is
acinetobacter spp.

All of them treated by the standard treatment

+ aminoglycoside or ciprofloxacin IV +
antipseudomonal penicillin or imipenem.

Sterilization and
Disinfection

Sterilization means ERADICATING all microorganisms and

SPORES.
Disinfection means the eradication of vegetative form
only leaving SPORES.
For sterilization, autoclave is the most common
instrument used.
Antiseptic is used on the surface of the body like alcohol,
chlorohexidine
Disinfectent is applied on metals and other instruments
like formaldehyde = formalin
Plastic materials are best sterilized using chemicals while
metalic instrument can be safely sterilized in the
autoclave.

antibiotics
Chemotherapeutic

organisms

agents that act on

Bacteriocidal: Penicillin,Cephalosporin,
Vancomycin, Aminoglycosides

Bacteriostatic:
Erythromycin,Clindamycin,Tetracycline

COMMON ANTIBIOTICS

Penicillins- penicillin G

Cephalosporins (II, III)-Cefruoxime, Ceftriaxone

Aminoglycosides- Gentamycin

Fluoroquinolones- Ciprofloxacin

Glycopeptides- Vancomycin

Macrolides- Erythromycin,

Tetracyclines-, Doxycycline

Prophylactic ab.
Prophylaxis

in cleancontaminated or high risk

clean wounds.
Antibiotic is given just before
patient sent for surgery.
Duration of antibiotic is
controversial (one dose-or
more , should not be used
more than 24 hour regimen )

Wound Classification

Thank u