4- surgical_infection.................ppt

Ttt

1. SURGICAL INFECTIONSSURGICAL INFECTIONS
Under supervision of : Under supervision of :
Dr. MOHAMMED AL-AKEELYDr. MOHAMMED AL-AKEELY

2. infectioninfection
Invasion of the body by pathogenic Invasion of the body by pathogenic
microorganisms microorganisms and reaction of and reaction of
the host to organisms and their the host to organisms and their
toxinstoxins

3. 
A surgical infection is an infection A surgical infection is an infection
which requires surgical treatment which requires surgical treatment
and has developed befor, or as a and has developed befor, or as a
complication of surgical complication of surgical
treatment.treatment.

4. 
could be life threatening could be life threatening

Accounts for 1/3 of surgical Accounts for 1/3 of surgical
patientspatients

Increased cost to healthcare Increased cost to healthcare

5. Some imp definSome imp defin..

Bacteremia: bacteria in bloodBacteremia: bacteria in blood

SIRS: systemic inflammatory response SIRS: systemic inflammatory response
syndrome (fever, tachycardia, syndrome (fever, tachycardia,
tachypnea, leukocytosis)tachypnea, leukocytosis)

Sepsis: documented infection & SIRASSepsis: documented infection & SIRAS

Septic shock: sepsis & hypotension Septic shock: sepsis & hypotension
refractory to fluid resuscitationrefractory to fluid resuscitation

6. 
Debridement-Debridement- necrotic, injured, dead necrotic, injured, dead
tissuetissue

Drainage-Drainage- abscess, infected fluidabscess, infected fluid

Removal-Removal- infection source, foreign bodyinfection source, foreign body

Supportive measures:Supportive measures:
• immobilizationimmobilization
• elevationelevation
• antibioticsantibiotics
Principles of surgical treatment Principles of surgical treatment

7. Common organisms Common organisms
Gram positive bacteria:Gram positive bacteria:

StreptococciStreptococci

StaphylococciStaphylococci

ClostridiaClostridia
Gram negative bacteria:Gram negative bacteria:

PseudomonasPseudomonas

E. coliE. coli

Bacteroid fragilisBacteroid fragilis

8. Streptococcal infectionsStreptococcal infections
1.1.CellulitisCellulitis
2.2.LymphangitisLymphangitis
3.3.LymphadenitisLymphadenitis
4.4.Necrotizing faciitisNecrotizing faciitis

9. cellulitiscellulitis

severe inflammation of dermal and subcutaneous layers of severe inflammation of dermal and subcutaneous layers of
the skin.the skin.

caused by normal skin flora(group A strept /staph)or by caused by normal skin flora(group A strept /staph)or by
exogenous bacteria.exogenous bacteria.

the bacteria can spread rapidly, entering the lymph nodes the bacteria can spread rapidly, entering the lymph nodes
and the bloodstream and spreading throughout the body.and the bloodstream and spreading throughout the body.

In rare cases, the infection can spread to the deep layer of In rare cases, the infection can spread to the deep layer of
tissue (tissue (Necrotizing faciitisNecrotizing faciitis).).

often occurs in broken skinoften occurs in broken skin..

10. cellulitiscellulitis

Signs & symptoms: Signs & symptoms: affected area is red, hot, and tender affected area is red, hot, and tender
with vague borders.with vague borders.

Most common sites Most common sites :: Face, hand and Face, hand and lower extremitieslower extremities..

RF:RF: old age & immunodeficiency. old age & immunodeficiency.

Diagnosis:Diagnosis: clinicallyclinically..

TX:TX:
1- 1- resting, elevation of the affected limb, debridement.resting, elevation of the affected limb, debridement.
2- ampicillin/amoxicillin in moderate (suspected strept) + 2- ampicillin/amoxicillin in moderate (suspected strept) +
flucloxacillin or dicloxacillin for mild (staph)flucloxacillin or dicloxacillin for mild (staph)

11. cellulitiscellulitis

12. ErysipelasErysipelas

ErysipelasErysipelas is the term used for a is the term used for a
more superficial infection of the more superficial infection of the
dermis and upper subcutaneous dermis and upper subcutaneous
layer that presents clinically with layer that presents clinically with
raised surface and well defined raised surface and well defined
edge.edge.

Erysipelas and cellulitis often coexist, Erysipelas and cellulitis often coexist,
so it is often difficult to make a so it is often difficult to make a
distinction between the two.distinction between the two.

13. ErysipelasErysipelas

14. Lymphangitis Lymphangitis

Lymphangitis is an inflammation of the Lymphangitis is an inflammation of the
lymphatic channels that occurs as a lymphatic channels that occurs as a
result of infection at a site distal to the result of infection at a site distal to the
channel.channel.

Streptococcus pyogenes. Streptococcus pyogenes.

Signs and symptoms: Signs and symptoms: deep reddening deep reddening
of the skin, warmth, with moderate pain of the skin, warmth, with moderate pain
and swelling. Lymphadenitis, chills and and swelling. Lymphadenitis, chills and
a high fever along. ( appears as red a high fever along. ( appears as red
streak).streak).

15. LymphangitisLymphangitis

Tx: Tx:
1-elevate and immobilize affected areas 1-elevate and immobilize affected areas
to reduce swelling, pain, and the to reduce swelling, pain, and the
spread of infection.spread of infection.
2- antibiotic.2- antibiotic.

16. LymphangitisLymphangitis

17. LYMPHADENITISLYMPHADENITIS

Lymphadenitis is an infection of the lymph Lymphadenitis is an infection of the lymph
nodes.nodes.

Lymphadenitis may occur after skin Lymphadenitis may occur after skin
infections or other bacterial infections, infections or other bacterial infections,
particularly those due to streptococcus or particularly those due to streptococcus or
staphylococcus.staphylococcus.

Swollen, tender, or hard lymph nodesSwollen, tender, or hard lymph nodes

Red, tender skin over lymph nodeRed, tender skin over lymph node

Lymph nodes may feel rubbery if an abscess Lymph nodes may feel rubbery if an abscess
has formed.has formed.

18. LYMPHADENITISLYMPHADENITIS

Treatment may include:Treatment may include:

Antibiotics to treat any underlying infectionAntibiotics to treat any underlying infection

Analgesics (pain killers) to control painAnalgesics (pain killers) to control pain

Anti-inflammatory medications to reduce Anti-inflammatory medications to reduce
inflammation and swellinginflammation and swelling

Cool compresses to reduce inflammation Cool compresses to reduce inflammation
and painand pain

Surgery may be needed to drain any Surgery may be needed to drain any
abscess.abscess.

19. LYMPHADENITISLYMPHADENITIS

20. Necrotizing fasciitis Necrotizing fasciitis
(flesh-eating disease)(flesh-eating disease)

Infection and necrosis of the deeper layers of skin and Infection and necrosis of the deeper layers of skin and
subcutaneous tissues.subcutaneous tissues.

2 types2 types: : l:polymicrobiall:polymicrobial
ll: monomicrobialll: monomicrobial (mostly group A strept)(mostly group A strept)

Signs and symptoms: Signs and symptoms: The infection begins locally, at a The infection begins locally, at a
site of trauma>>intense pain>> then tissue becomes site of trauma>>intense pain>> then tissue becomes
swollen (hrs.)swollen (hrs.)

Common sitesCommon sites: : abdominal wall, perineum, and limbs.abdominal wall, perineum, and limbs.

Diagnosis:Diagnosis: visual examination & microscopic visual examination & microscopic
evaluation of tissue samplesevaluation of tissue samples..

21. Necrotizing fasciitisNecrotizing fasciitis

RF:RF: diabetes, abdominal surgery, drug diabetes, abdominal surgery, drug
addict and traumaaddict and trauma..

Tx:Tx:
1-Early medical treatment (combination of 1-Early medical treatment (combination of
intravenous antibiotics including penicillin, intravenous antibiotics including penicillin,
vancomycin, and clindamycin)vancomycin, and clindamycin)
2-Cultures are taken to determine appropriate 2-Cultures are taken to determine appropriate
antibiotic antibiotic
3-aggressive surgical debridement ( no 3-aggressive surgical debridement ( no
definitive boundries!!)definitive boundries!!)

High mortality rateHigh mortality rate (75%) if left untreated.(75%) if left untreated.

22. Necrotizing fasciitisNecrotizing fasciitis

23. 
Abscess: Abscess: is a collection of pus (dead is a collection of pus (dead
neutrophils) that has accumulated in a cavity neutrophils) that has accumulated in a cavity
formed by the tissue formed by the tissue

It is a defensive reaction of the tissue to It is a defensive reaction of the tissue to
prevent the spread of infectious materials to prevent the spread of infectious materials to
other parts of the bodyother parts of the body

As As Staphylococcus aureusStaphylococcus aureus bacteria is a common bacteria is a common
cause, an anti-staphylococcus antibiotic such cause, an anti-staphylococcus antibiotic such
as flucloxacillin or dicloxacillin is usedas flucloxacillin or dicloxacillin is used

Incision and drainage is a common surgical Incision and drainage is a common surgical
intervention in case of abscess intervention in case of abscess
Staphylococcal InfectionsStaphylococcal Infections

24. Staphylococcal InfectionsStaphylococcal Infections
1.1.Furuncle-Furuncle- infection of one hair follicle / infection of one hair follicle /
sweat glandssweat glands
2.2.Carbuncle-Carbuncle- extension of furuncle into subcut. extension of furuncle into subcut.
Tissue with possible formation of abscess. Tissue with possible formation of abscess.
“ “usually more than one furuncle”usually more than one furuncle”
common in diabetic patient common in diabetic patient
common sites- back, back of neckcommon sites- back, back of neck
Treatment: drainage, antibiotics, control Treatment: drainage, antibiotics, control
diabetesdiabetes

25. Staphylococcal InfectionsStaphylococcal Infections

26. Clostridial infectionsClostridial infections
1.1.Gas gangreneGas gangrene
2.2.TetanusTetanus
3.3.Pseudomembranous colitisPseudomembranous colitis

27. GAS GANGRENEGAS GANGRENE

is a bacterial infection that produces gas in gangrenous is a bacterial infection that produces gas in gangrenous
tissues usually caused by Clostridium perfrengins tissues usually caused by Clostridium perfrengins
bacteria.bacteria.

It is a medical emergencyIt is a medical emergency (Progression to toxemia and (Progression to toxemia and
shock is often very rapid)shock is often very rapid)

Large wounds contaminated by soil.Large wounds contaminated by soil.

It results in rapid myonecrosis, swelling, seropurulent It results in rapid myonecrosis, swelling, seropurulent
discharge, foul smelling wound, crepitus in discharge, foul smelling wound, crepitus in
subcutaneous tissue.subcutaneous tissue.

28. GAS GANGRENEGAS GANGRENE

X-ray: X-ray: gas in muscle and under skin.gas in muscle and under skin.

Tx: Tx:
1-Wound exposure, debridement , 1-Wound exposure, debridement ,
drainage.drainage.
2-Penicillin, clindamycin, metronidazole2-Penicillin, clindamycin, metronidazole
3-Hyperbaric oxygen chamber3-Hyperbaric oxygen chamber

29. GAS GANGRENEGAS GANGRENE

30. TETANUSTETANUS
Cl. Tetani, produce neurotoxinCl. Tetani, produce neurotoxin
Penetrating wound Penetrating wound ( rusty nail, thorn )( rusty nail, thorn )
Incubation period: 7-10 daysIncubation period: 7-10 days
Usually wound healed when symptoms appearUsually wound healed when symptoms appear
Trismus- first symptom, stiffness in neck & backTrismus- first symptom, stiffness in neck & back
Anxious look with mouth drawn up Anxious look with mouth drawn up ( risus sardonicus)( risus sardonicus)
Progressive dysphasia, dysphagia, dyspnea & Progressive dysphasia, dysphagia, dyspnea &
tonic convulsion tonic convulsion
Death by exhaustion, aspiration or asphyxiationDeath by exhaustion, aspiration or asphyxiation

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

32. 
Superinfection in patients in long term oral Superinfection in patients in long term oral
antibiotic therapyantibiotic therapy

Cl. DifficileCl. Difficile

Watery diarrhea, abdominal pain, feverWatery diarrhea, abdominal pain, fever

Diagnosis needs Sigmoidoscopy, stool- culture Diagnosis needs Sigmoidoscopy, stool- culture
and toxin assayand toxin assay

Treatment :Treatment :
stop offending antibioticstop offending antibiotic
oral vancomycin/ metronidazoleoral vancomycin/ metronidazole
rehydration, isolate patient rehydration, isolate patient
PSEUDOMEMBRANOUSPSEUDOMEMBRANOUS COLITISCOLITIS

33. PseudomonasPseudomonas

Opportunestic bacteria that may cause surface Opportunestic bacteria that may cause surface
infections, but may also cause serious and lethal infections, but may also cause serious and lethal
infection.infection.

Enter the body through minor skin abrasion, Enter the body through minor skin abrasion,
ventilator tubes, urinary catheters and IV lines >>> ventilator tubes, urinary catheters and IV lines >>>
therefore it istherefore it is common in ICU.common in ICU.

Can cause Can cause septecimiaseptecimia (particularly in burn (particularly in burn
wounds)wounds)

Tx: Tx: aminoglycosides, piperacillin, ceftazidineaminoglycosides, piperacillin, ceftazidine..

34. E. coliE. coli

Normal intestinal flora, facultative Normal intestinal flora, facultative
anearobes.anearobes.

May cause May cause circulatory collapsecirculatory collapse (due to (due to
endotoxin), wound infections, meningitis, endotoxin), wound infections, meningitis,
endocarditis, abdominal abscess & UTI.endocarditis, abdominal abscess & UTI.

Tx: Tx: ampicillin, aminoglycosides, ampicillin, aminoglycosides,
cephalosporine.cephalosporine.

35. Bacteroides fragilisBacteroides fragilis

Normal flora of mouth and colon, anearobic.Normal flora of mouth and colon, anearobic.

Produce foul smelling pus, gas in surrounding Produce foul smelling pus, gas in surrounding
tissues & necrosis.tissues & necrosis.

Responsible for intraabdominal & gyne. Responsible for intraabdominal & gyne.
infection.infection.

Causes spiking fever, jaundice & leukocytosis.Causes spiking fever, jaundice & leukocytosis.

Tx: Tx:
1.1.Surgical drainage, excision.Surgical drainage, excision.
2.2.Clindamycin, metronidazoleClindamycin, metronidazole..

36. Hospital aquired infectionsHospital aquired infections

The most common is UTIThe most common is UTI

The most common causing The most common causing
death is pneumonia.death is pneumonia.

37. 
38% of all surgical infections38% of all surgical infections

Infection within 30 days of operationInfection within 30 days of operation

Classification:Classification:
Superficial: Superficial: Superficial SSI–infection in subcutaneous plane (47%)Superficial SSI–infection in subcutaneous plane (47%)
Deep:Deep: Subfascial SSI-Subfascial SSI- muscle plane (23%)muscle plane (23%)
Organ/ space SSI-Organ/ space SSI- intra-abdominal, other spaces (30%)intra-abdominal, other spaces (30%)

Staph. aureus-Staph. aureus- most common organism most common organism

E coliE coli, Entercoccus ,other Entetobacteriaceae- deep , Entercoccus ,other Entetobacteriaceae- deep
infectionsinfections
B fragilis – intrabd. abscessB fragilis – intrabd. abscess
Surgical site infection (SSI)Surgical site infection (SSI)

38. 
Risk factors: Risk factors: age, malnutrition, obesity, age, malnutrition, obesity,
immunocompromised, poor surg. tech, immunocompromised, poor surg. tech,
prolonged surgery, preop. shaving and prolonged surgery, preop. shaving and
type of surgery.type of surgery.

Diagnosis:Diagnosis:
Sup.SSI- erythema, oedema, discharge and pain Sup.SSI- erythema, oedema, discharge and pain
Deep infections- no local signs, fever, pain, Deep infections- no local signs, fever, pain,
hypotension. hypotension. need investigations. need investigations.

TreatmentTreatment:: surgical / radiological interventionsurgical / radiological intervention. .
Surgical site infection (SSI)Surgical site infection (SSI)

39. Intra-abdominal infectionsIntra-abdominal infections

GeneralizedGeneralized

LocalizedLocalized

Prevention- good tech., avoid bowel Prevention- good tech., avoid bowel
injury, good anastomosis.injury, good anastomosis.

Diagnosis- History, exam., investigations Diagnosis- History, exam., investigations
CT scan.CT scan.

Treatment- surgery/ interventionTreatment- surgery/ intervention
Antibiotics Antibiotics (aerobe+ anaerobe)(aerobe+ anaerobe)
Surgical site infection (SSI)Surgical site infection (SSI)

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

41. UTIUTI

Diagnostic test:Diagnostic test:

-urinalysis (nitrate, estrase)-urinalysis (nitrate, estrase)

-culture-culture

-urine microscopy (WBC>10)-urine microscopy (WBC>10)

The common org. is:The common org. is:

- - E. coliE. coli, klebsiella, enterococcus & , klebsiella, enterococcus &
staph. aureusstaph. aureus

42. TREATMENTTREATMENT

Ab.with gram (-) spectrumAb.with gram (-) spectrum
-sulphamethoxasole-sulphamethoxasole
-trimethoprim-trimethoprim
-gentamycin-gentamycin
-ceprofloxacin-ceprofloxacin

Check culture &sensitivityCheck culture &sensitivity

43. pneumoniapneumonia
Rout of infectionRout of infection::
-gross aspiration during anesthesia-gross aspiration during anesthesia
or intubation. Pathogen includesor intubation. Pathogen includes
anaerobic organism & gram(-) anaerobic organism & gram(-)
bacilli.bacilli.

-- Atelectasis: the collapsed lung may Atelectasis: the collapsed lung may
become secondarily infectedbecome secondarily infected
-contiguous spread from another site.-contiguous spread from another site.

44. pneumoniapneumonia
Sing & symptoms :Sing & symptoms :
• People with pneumonia often have one or more
of these symptoms: Fever, productive cough, Fever, productive cough,
shortness of breath, hypoxia and chest pain.shortness of breath, hypoxia and chest pain.
• Chest x-ray & sputum culture are important to Chest x-ray & sputum culture are important to
confirm the diagnose. confirm the diagnose.

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

46. 
If the pt. is comatose or has head If the pt. is comatose or has head
trauma, DM, or renal failure the org. trauma, DM, or renal failure the org.
usually is s.aureus & there is risk of usually is s.aureus & there is risk of
MRSA we add MRSA we add vancomycinvancomycin

If the pt. take high dose of If the pt. take high dose of
glucocorticoides the org. usually is glucocorticoides the org. usually is
legionella we add legionella we add macrolide macrolide
(azithromycin)(azithromycin)

47. 
If the pt. has malnutrition, structural lung If the pt. has malnutrition, structural lung
disease, glucocorticoid therapy the org. disease, glucocorticoid therapy the org.
usually is pseudomonas.ausually is pseudomonas.a

Also if the pt. has Hx of neuro.surg. ,head Also if the pt. has Hx of neuro.surg. ,head
trauma, ARDS, aspiration the org. usually is trauma, ARDS, aspiration the org. usually is
acinetobacter spp. acinetobacter spp.

All of them treated by the standard treatment All of them treated by the standard treatment
+ + aminoglycoside or ciprofloxacin IVaminoglycoside or ciprofloxacin IV + +
antipseudomonal penicillin or imipenem. antipseudomonal penicillin or imipenem.

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

49. antibioticsantibiotics

Chemotherapeutic agents that act on Chemotherapeutic agents that act on
organismsorganisms

Bacteriocidal:Bacteriocidal: Penicillin,Cephalosporin, Penicillin,Cephalosporin,
Vancomycin, AminoglycosidesVancomycin, Aminoglycosides

Bacteriostatic:Bacteriostatic:
Erythromycin,Clindamycin,TetracyclineErythromycin,Clindamycin,Tetracycline

50. COMMON ANTIBIOTICSCOMMON ANTIBIOTICS

PenicillinsPenicillins- - penicillin Gpenicillin G

Cephalosporins (II, III)Cephalosporins (II, III)--Cefruoxime, CeftriaxoneCefruoxime, Ceftriaxone

AminoglycosidesAminoglycosides- - GentamycinGentamycin

FluoroquinolonesFluoroquinolones- - CiprofloxacinCiprofloxacin

GlycopeptidesGlycopeptides- - VancomycinVancomycin

MacrolidesMacrolides- - Erythromycin, Erythromycin,

TetracyclinesTetracyclines--, Doxycycline, Doxycycline

51. Prophylactic ab.Prophylactic ab.

Prophylaxis in clean-Prophylaxis in clean-
contaminated or high risk contaminated or high risk
clean wounds.clean wounds.

Antibiotic is given just before Antibiotic is given just before
patient sent for surgery.patient sent for surgery.

Duration of antibiotic is Duration of antibiotic is
controversial (one dose-or controversial (one dose-or
more , should not be used more , should not be used
more than 24 hour regimen )more than 24 hour regimen )

52. Wound ClassificationWound Classification

Wound class Definition Example Infection
rate (%)
Clean Nontraumatic, elective
surgery. GI tract,
respiratory tract, GU tract
not entered
Mastectomy
Vascular
Hernias
2%
Clean-
contaminated
Respiratory, GI, GU tract
entered with minimal
contamination
Gastrectomy
Hysterectomy
< 10%
Contaminated Open, fresh, traumatic
wounds, uncontrolled
spillage, minor break in
sterile technique
Rupture appy
Emergent
bowel resect.
20%
Dirty Open, traumatic, dirty
wounds; traumatic
perforation of hollow
viscus, frank pus in the
field
Intestinal
fistula
resection
28-70%

53. Thank uThank u