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Seminar on Surgical Infections

1. Seminar on Surgical infections Prepared By: Dr. Atinkut Abesha Moderator: Dr. Tilahun ( G.Surgeon ) Date: 19/11/2014 E.C Surgical Infections: Prepared By: Atinkut A. (Medical Intern)

2. Outlines 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 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 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 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)

6. Surgical Infections… Introduction Host Defense Mechanisms: Surgical Infections: Prepared By: Atinkut A. (Medical Intern)

7. Surgical Infections… Introduction 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) eradication containment Regional infection Systemic infection

8. Surgical Infections… Definition 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)

9. Surgical Infections… Etiologies Surgical Infections: Prepared By: Atinkut A. (Medical Intern)

10. Surgical Infections… Etiologies Surgical Infections: Prepared By: Atinkut A. (Medical Intern)

11. Surgical Infections… Route of infection Route of infection: Direct inoculation Airborne contamination Haematogenous/lymphatic seeding Surgical Infections: Prepared By: Atinkut A. (Medical Intern)

12. Surgical site infections Surgical infections other than SSIs Surgical Infections: Prepared By: Atinkut A. (Medical Intern)

13. I. Surgical Site Infections 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 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)

15. I. Surgical wound… Classification Surgical Infections: Prepared By: Atinkut A. (Medical Intern)

16. I. Surgical wound… Classification 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 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 Surgical Infections: Prepared By: Atinkut A. (Medical Intern) Classification of Surgical Site infections:

19. I. Surgical Site Infections… Classification 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 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 Risk factors for development of surgical site infections: Surgical Infections: Prepared By: Atinkut A. (Medical Intern) Patient factors Microbial factors Local factors

22. I. Surgical Site Infections… Risk factors Patient factors Surgical Infections: Prepared By: Atinkut A. (Medical Intern) 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) 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) Microbial factors Prolonged hospitalization (leading to nosocomial organisms) Toxin secretion Resistance to clearance (e.g., capsule formation)

25. I. Surgical Site Infections… C/F 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 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 III. Cold abscess: Treatments Anti tuberculosis regimen/leprosy Excision Surgical Infections: Prepared By: Atinkut A. (Medical Intern)

50. II. Surgical Infections other than SSIs 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 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 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 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 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 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 5. Ludwig’s Angina Complication Compromise airway Septicemia Surgical Infections: Prepared By: Atinkut A. (Medical Intern)

57. II. Surgical Infections other than SSIs 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 Schwartz's Principles of Surgery 11 th edition Bailey & Loves Short Practice of Surgery 27 th edition Manipal Manual Of Surgery 4 th Edition Uptodate Surgical Infections: Prepared By: Atinkut A. (Medical Intern)

59. Surgical Infections: Prepared By: Atinkut A. (Medical Intern)