Post operative infections

AIM
 This project was done with the aim, to make
awareness about the fact that even after
undergoing surgery for the treatment, a
patient’s life should not be considered as totally
out of the danger, as there arises a possibilility
of having a post operative or a surgical site
infection.
 Cancer patients are prone to this danger due to
the consumption of different chemotherapeutic
drugs and thus becoming
immunocompromised.
 Even after, the surgical procedure has been
carried out in a very sophisticated hospital, the
 Public Health Importance
of SSIs
 Postoperative infection is a major cause of
Postoperative infection is a major cause of
patient injury, mortality and health care cost: 
 second most common nosocomial infection
(24% of all nosocomial infections)
 An estimated 2.6 percent of nearly 30 million
operations are complicated by surgical site
infections (SSIs) each year.   
 Each infection is estimated to increase a
hospital stay by an average of 7 days and add
over $3,000 in charges (1992 data). 
 Appropriate preoperative administration of
antibiotics is effective in preventing infection.
 According to the CDC’s National Nosocomial
Infections Surveillance (NNIS) system :
 38% of all nosocomial infections in surgical
 What is Post operative
infection?
 A post operative or surgical site
infection, is the infection that occurs after
an operation or a surgery.
 Post Operative Infections (POIs) are also
known as ‘Surgical Site
Infections’(SSIs) or ‘Wound
Infections’(WIs) .
 The CDC definition states that only
infections occurring within 30 days of
surgery (or within a year in the case of
implants) should be classified as SSIs.
 Occurrence
 A surgical site infection can occur when the
infectious agents from the skin, other parts of
the body or the environment enter the surgical
site and multiply in the tissues. As a result,
there may be inflammation, pus, swelling, pain
and fever. The infections acquired in the
hospital cause anxiety & discomfort, complicate
illness and delay the recovery process.
 Following three factors are the determinants of
any infectious process:
 The infecting organism (in surgical patients,
usually bacteria).
 The environment in which the infection takes
 CDC Definition of Surgical
Site Infections
 Superficial incisional surgical
site infections
 These involve only the skin and
subcutaneous tissue around the
incision. Symptoms of these
infections include pain or
tenderness, localised swelling,
redness or heat .

 Deep-incisional surgical site

infections
 These involve deep soft tissues,
such as the fascia and muscles.
Symptoms include an abscess ,
fever (>38°C), localised pain or
tenderness .

 Organ / Space surgical site

infections
 These involve any part of the
anatomy (e.g. organs, spaces)
other than the incision that was
manipulated during the operative
procedure.
 Stratification of risk for SSIs
 Class1 : Clean
 Non-traumatic, primarily
closed; no acute
inflammation ; no break in
technique; respiratory,
gastrointestinal, biliary and
genitourinary tracts not
entered.
 Class3 :
Contaminated-Non-
purulent inflammation; gross
spillage from the gastro-
intestinal tract; entry into
biliary or genitourinary tract
in the presence of infected
bile or urine; major break in
technique.
 Class 2 : Clean
Contaminated- Elective
opening of respiratory,
gastrointestinal, biliary or
genitourinary tract with
minimal spillage (e.g.
appendectomy) not
encountering infected urine or
bile; minor technique break.
 Class 4 : Dirty-
 Purulent inflammation (e.g.
abscess); preoperative
perforation ofrespiratory,
gastrointestinal , biliary or
genitourinary tract.
 Rates of infections
 Incidence varies from 1.5 to 13 / 100
operations.
 Infection rates in US National Nosocomial
Infection Surveillance (NNIS) system
hospitals were reported to be: 2.1 %
(clean), 3.3 % (clean-contaminated), 6.4%
(contaminated ) & 7.1% (dirty wounds) .
 Probability of SSI = x + a (bacteria) + b
(environment: local factors) + c (host
defense mechanisms: systemic factors) –
omitted.
 Nature, Diagnosis and
Treatment of Surgical
Infections
Different kinds of SSIs, caused by
different kinds of pathogens are as
follows:
 Soft tissue infections,
 Necrotizing soft tissue infections,
 Intra abdominal and retroperitoneal infections,
 Prosthetic (Catheter) device associated infections,
 Central nervous system infections,
 Oroesophageal infections,
 Blood stream infections (BSI) / Bacteremia.
 Soft tissue infections
Subcutaneous abscess - pus filled central
portion surrounded by a vascularized zone. e.g. Superficial
abscesses on trunk, head (S.aureus and Streptococci) .Cellulitis
- intact blood supply & viable tissue, with inflammation &
edema. Treatment done with antibiotic therapy.

 Necrotizing Soft tissue infections

A layer of necrotic tissue, not surrounded by a clear
boundary. e.g. Clostridial myonecrosis or. gas gangrene
(C.perfringens, C.septicum). Treatment done by removing
areas of necrotic tissue.
 Intra abdominal and retroperitoneal
infections
These infections include Intra abdominal abscesses,
sub hepatic abscesses, enteritis etc. Yield different aerobic and
anaerobic pathogens. Symptoms include fever, abdominal
pain, fluid shifts. Treatment done by operative intervention,
drainage, and antibiotic therapy.

 Central nervous system infections

Prosthetic device associated infections
Usually caused by the exogenous & endogenous microflora of body e.g.
endocarditis. (Staphylococcus aureus, Coag. negative staphylococci ,Candida), These
infections results in complications of vascular grafts, cardiac valves, pacemakers and
artificial joints. Treatment done by intensive antibiotic therapy & replacement with a new
uninfected device.

Oroesophageal infections
Infections of upper GI tract that occurs due to extensive use of cancer
chemotherapy. As a consequence mucosal candidiasis (Candida spp.), substernal
burning (C.esophagitis), ulcerations (Cytomegalovirus and Herpes virus) occur.

Blood stream infections (BSI) / Bacteremia

Primary :- Isolation of bacterial blood pathogen in absence of infection at
another site. Secondary : - When bacteria are isolated from the blood during an infection
with the same organism at another site. i.e. UTI, LRI. Sources :- vascular catheters,
multidose medication vials, autoinfection. Causative agents are gram positive bacteria
and fungi.
 Diagnosis and Treatment

 S&S:  Treatment:
 -fever  skin and subq in involved
 -swelling area opened – underlying
fascia examined for
 -erythema dehiscence
 -localized pain  -gram stain any purulent
 -incision tenderness  drainage
 -leukocystosis variable  -debridement necrotic
 Most infections are tissue
superficial  -antibiotics only for

anduncomplicated complicated infections or

patient high risk for
dissemination of infection
(i.e. diabetics;
immnunocompromised)
 Pathogenesis of SSI
 Relationship equation

Dose of bacterial contamination x

Virulence Resistance of
host

SSI
Risk
Pathogenesis of SSIs

Pseudomonas
aeruginosa
Enterococcus

Coag-neg staphylococcl

E-coli

Staphylococcus aureus

Other
 SSI Risk Factors
 Age Hair removal/Shaving
 Obesity Duration of surgery
 Diabetes Surgical technique
 Malnutrition Presence of drains
 Prolonged Inappropriate use of
preoperative stay antimicrobial
 Infection at remote prophylaxis
site
 Systemic steroid
use
 Nicotine use
 Prevention
 Use prophylactic antibiotics
appropriately (selection, timing,
duration of AP)
 Engineering & architectural
advances in modern operating
rooms (UV, laminar flow ventilation
systems) .
 Patients Preoperative Preparations
:
 Avoid shaving operative site (hair
removal technique)
 Maintain glucose control
 oxygen tension
 Thermoregulation
 Operating room team discipline
 Surgical Attire (Scrub suits,
Cap/hoods, Shoe covers, Masks,
Gloves , Gowns)
 METHODS
 Collection and Transport of Samples:
 Blood sample :- The elbow skin disinfected by spirit
and 5% carbolic acid solution. A fixed vein located
and venipuncture performed. Required amount of
blood sample collected in special, anticoagulant
(Sodium citrate) containing, clean and sterile, blood
collecting glass vials.
 Urine sample :- The vulva or. penis, wiped with
cotton swab soaked in normal saline and 5 -10 ml.
urine sample collected in sterile and wide mouthed
screw capped bottles.
 Pus sample :- Lesion first cleaned with a swab
soaked in warm normal saline, then pus aspirated
with syringe and carried in sterile container to the
laboratory.
 Tip of Central Line as sample :- This is the part of
a catheter, inserted during operation for monitoring
fluid balance and infectious agents. It was also taken
for detection of infection. This part of the catheter
 Culture
 The clinical samples collected in the above manner were
inoculated by simple streaking method on the nutrient
agar medium plates and then incubated at 37 ˚C for 24
hrs. After incubation the bacterial growth was observed
and then to further differentiate the bacterial colonies,
these were inoculated on selective media, as Mac
Conkey’s agar and Blood Agar medium and after
incubation at 37 ˚C for 24 hours., bacterial growth was
observed

 Isolation and characterization of the bacterial

isolates
 Isolation :- The isolation was done on the nutrient agar
medium, Mac Conkey’s Agar medium and Blood Agar
media. The samples collected were inoculated on these
media plates and colonial growth was observed. The
isolated bacterial colonies were sub cultured and
incubated .These plates were observed for growth of pure
colonies.
Details of the patients, test
samples and identification
of the microorganisms.
S.No Patient’s name Age / Date of Date of Sample Microorganisms identified
Sex surgery sample type
collection

Sheela Sharma 65/F 5.5.06 8.5.06 Blood Sample was sterile after 72 hours
of aerobic incubation at 37 ˚C.

Purushottam Das 60/M 6.5.06 8.5.06 Urine Sample was sterile after 48 hours
of aerobic incubation at 37 ˚C.

Mahaveer Prasad 50/M 9.5.06 14.5.06 Pus Pseudomonas species over 1 lac
organisms/cc. cultured.

Mr. Pala 56/M 10.5.06 16.5.06 Urine Sample was sterile after 72 hours
of aerobic incubation at 37 ˚C.

Prem Kumar 45/M 15.5.06 19.5.06 Urine Sample was sterile after 48 hours
of aerobic incubation at 37 ˚C.

Ranjeet 50/M 16.5.06 18.5.06 Urine Sample was sterile after 72 hours
of aerobic incubation at 37 ˚C.

Nitesh Kumar 48/M 20.5.06 24.5.06 Pus E.coli over 1 lac organisms/cc.
cultured.

Mrs. Usha Singhal 39/F 24.5.06 1.6.06 Tip of Central Sample was sterile after 72 hours
line of aerobic incubation at 37 ˚C.
Godawari devi 30/F 24.5.06 26.5.06 Urine Sample was sterile after 72 hours of
aerobic incubation at 48 ˚C.

Hetram 25/M 25.5.06 27.5.06 Urine Sample was sterile after 72 hours of
aerobic incubation at 37 ˚C.

Mr. Sardul.Singh 52/M 31.5.06 2.6.06 Pus Pseudomonas species over 1 lac
organisms/cc. cultured.

Mannu Ram 60/M 2.6.06 5.6.06 Urine Sample was sterile after 72 hours of
aerobic incubation at 37 ˚C.

Mast. Ajay Kumar 15/M 3.6.06 13.6.06 Pus Sample was sterile after 72 hours of
aerobic incubation at 37 ˚C.

Narayani devi 60/F 9.6.06 10.6.06 Pus Pseudomonas species over 1 lac
organisms/cc. cultured.

Mrs.Prabha 35/F 10.6.06 12.6.06 Urine Sample was sterile after 48 hours of
aerobic incubation at 37 ˚C.

Shyam Sunder Gupta 60/M 11.6.06 19.6.06 Urine Sample was sterile after 48 hours of
aerobic incubation at 37 ˚C.

Mohini devi 65/F 19.6.06 24.6.06 Pus Staphylococci coagulase positive,

cultured.

Fojer 55/M 19.6.06 22.6.06 Urine Sample was sterile after 72 hours of
aerobic incubation at 37 ˚C.

Girdhari devi 50/F 20.6.06 23.6.06 Blood Sample was sterile after 48 hours of
aerobic incubation at 37 ˚C.

Chagani 66/F 21.6.06 23.6.06 Pus E.coli over 1 lac organisms/cc. cultured.
devi
 SUMMARY
 Twenty hospitalized surgical cancer patients with suspicion
of having POI were studied. The selection of the patients for
the present study was made on the basis of their certain
clinical syndromes / effects e.g. Pain, swelling,
inflammation, fever, pus formation, pneumonia, diarrhoea,
UTI etc.
 Clinical samples from all those patients were collected and
tested for the presence of any pathogenic microorganisms.
Samples from 6 patients showed positive results e.g.
significant bacterial growth (< 10 5 CFU / ml.) on nutrient
agar medium. The isolation, identification, and confirmation
of microorganisms was done by different morphological and
biochemical tests.
 After screening, Pseudomonas, E.coli, Staphylococci were
found to be the causative agents of SSIs / POIs.
Pseudomonas aeruginosa was found to be the major
causative agent of SSIs / POIs.
 Even after being a short term study, it has demonstrated
that Pseudomonas aeruginosa is the predominant cause of
SSIs / POIs.