SURGICAL SITE INFECTIONS and Management.pdf

Etiology, Types, Pathogenesis and Management of various surgical site infections

1. DR NAVEEN PATIDAR
ASSISTANT PROFESSOR
DEPARTMENT OF GENERAL SURGERY
SURGICAL INECTIONS

2. LEARNING OBJECTIVES
YOU SHOULD BE ABLE TO
DEFINE SURGICAL INFECTIONS
DESCRIBE AETIOLOGY
DESCRIBE PATHOGENESIS OF SURGICAL
INFECTIONS.

3. DEFINITION
INFECTION:-Invasion of organism into tissues
following a breakdown of local and systemic host
defences.
SURGICAL INFECTION :-An infection which
requires surgical treatment and has developed
before or as a complication of surgical procedure.

4. COMMAN ORGANISM CAUSING
SURGICAL INFECTIION
STREPTOCOCCI :-S. Pyogenes
S. Faecalis
STAPHYLOCOCCI:-S. Aureus, MRSA
S.Epidermidis
CLOSTRIDIA :-C. perfringes
C. tetani
C. difficile
AEROBIC GRAM (-) BACILLI :-E. coli
klebsiella
proteus
pseudomonas
BACTEROIDES

6. HOST DEFENCE

7. PROPHYLAXIS
TREATMENT OR ACTIONS TAKEN TO PREVENT A
DISEASE.
ANTIBIOTIC :-
Empirical cover against expected pathogens.
i/v administration within 1 hour of incision
Repeat if long duration of surgery(>4hr) or excessive blood
loss
Based on type of surgery

8. FACTORS DETERMINING WOUND
INFECTION
Host response
Virulence and inoculumof infective agent
Vascularityand health of tissue being invaded
Presence of dead or foreign tissue
Presence of antibiotics during decisive period

9. DECISIVE PERIOD
4 hour interval before bacterial growth
becomes established after breach in tissue.
Prophylactic antibiotics?

10. RISK FACTORS OF SURGICAL
INFECTIONS
Malnutrition (obesity , weight loss)
Metabolic disease ( diabetes, uraemia, jaundice)
Immunosuppression(cancer, aids, steroids,
chemotherapy and radiotherapy)
Colonisationand translocation in gastrointestinal
tract
Poor perfusion( systemic shock or ischemia)
Foreign body material
Poor surgical techinque(dead space, haematoma)

12. SOURCES OF INFECTION
ENDOGENOUS/PRIMARY :-Organisms
present on or in the patient
EXOGENOUS/SECONDARY :-Organisms
acquired from a source outside the body such as
ot, ward. Cause of hospital acquired infection.

13. CLINICAL PRESENTATION
LOCALISED :-ABSCESS
CELLULITIS
LYMPHANGITIS
CARBUNCLE
ERYSIPELAS
NECROTISING FASCIITIS
SPECIFIC INFECTIONS:-
GAS GANGRENE, TETANUS
SYSTEMIC :-BACTERAEMIA
SEPTICAEMIA
SIRS

14. SURGICAL SITE INFECTION
An infection that occurs after surgery in the part
of the body where the surgery took place.

15. MINOR SSI:-discharge
pus/infected serous fluid
but not asso. with excessive
discofort, systemic signs or
delay in return home
MAJOR SSI :-significant
quantity of pus
systemicalill
delayed return home

16. ABSCESS
Localisedcollection of pus lined by
granulation tissue covered by pyogenic
membrane.

17. CLINICAL PRESENTATION
PUS:-DEAD wbcs, BACTERIAS, TOXIN, NECROTIC
MATERIAL.
Commanbacterias:-staphylococcus aureus
Streptoccocuspyogens
Gram negative bacterias
Anaerobes
Feature of acute inflammation

18. MANAGEMENT
BLOOD
INVESTIGATIONS
DIAGNOSIS:-
CLINICAL, XRAY,
USG, MRI
TREAMENT:-
MEDICAL
MANAGEMENT,
DRAINAGE,
ASPIRATION

19. CELLULITIS
Non-suppurative
spredinginflammation
Subcutneoustissue and
facial planes
Poor localisation
Strep, staph, clostridia

20. LYMPHANGITIS
Acute non
suppurative
Infection
Spreading
inflammation
Lymphatic of skin
and subcutaneous
tissue
Streaky redness
with blachingon
pressure

21. ERYSIPELAS
Acute spreding
inflammation of upper
dermis and superficial
lymphatics
Mc site –orbit, face,
ear lobule
More superficial than
cellulitis

22. NECROTISING FASCITIS
Spreading
inflammation of skin,
deep fascia, soft
tissue with extensive
destruction,
toxaemia
Gangrene ,
microvasculature
thrombosis
Mixed organism
infection

23. CARBUNCLE
Infective gangrene of
skin and subcutaneous
tissue
Staph aureus
Nape of neck and
back
Diabetic
Group of hair follicles
; cluster of furuncles.

24. GAS GANGRENE
Clostridium perfringens/
septicum
Soil / faeces
Anaerobic condition
Foreign material
Foul smell
Exotoxin:-collagenase,
hyluronidase, proteases,
alpha toxins

25. TETANUS
Clostridium tetani
Anaerobic
Penetrating wounds , soil
Exotoxintetanospasmin:-
myoneuraljunction
Incubation period-7-10 days
Trismus,opsithotonus, respiratory
arrest
Risussardonicus

27. SIRS( SYSTEMIC INFLAMMATORY
REPONSE SYNDROME)
SYSTEMIC RESPONSE TO SEVERE INFECTION

29. OTHER INFECTIONS
ACTINOMYCOSIS :-A. ISRAELII
MADURA FOOT:-
ACTNIMYCES, NOCARDIA
HEPATITIS
HIV

31. PREOP PREPERATION

32. SURGICAL WOUND CLASSIFICATION

33. ANTIBIOTIC PROPHYLAXIS

34. SCRUBBING AND SKIN PREPERATION

36. ANTIBIOTICS
Based on organism and sensitivity
Narrow spectrum :-sensitive infection
MRSA, ESBL
Broad sprectrum:-organism not known
multi-bacterial infection

37. COMMAN MISTAKES
All post op fevers require antibiotic
I/V antibiotic are more efficacious than oral
More antibiotics are better.

38. DOSE AND DOSE ADJUSTMENTS
TIME DEPENDENT ANTIBIOTIC :-beta-lactams,
glycopeptides, macrolides:-prolong infusions
CONCENTRATION DEPENDENT ANTIOBIOTICS :-
Flouroquinolones, Aminoglycosides:-single shot high
dose

39. TIMING
SEPTIC SHOCK :-as soon as possible (within 1 hr)
Prophylaxis:-within 1hr
repeat:-more than 4hr
blood loss > 2000ml
use narrow spectrum
discontinue within 24hr post op

40. HOW TO CHOOSE ANTIBIOTIC
SOURCE:-site/source
pathogen
empericaltherapy:-local data
Spectrum
Penetration?
Route
Culture and sensitivity

41. WHEN TO STOP ANTIBIOTIC
Usually 4-7 days
Prophylaxis-24hr
Clinical indicators are best guide
Prolong treatment harmful

42. Avoid bacteriostaticdrugs in sepsis and immuno-
compromised (macrolides, linezolid, tigecycline)
Pip/tazoand carbapenemare good as monotherapy
Avoid use 2 or more antibiotic of same class.
Avoid irrational combination therapy
Send culture frequently