surgicalinfections-120813212834-phpapp02(1).pptx

seminar

1. MEKELLE UNIVERSITY COLLEGE OF HEALTH SCIENCE Surgery Department Department of public health officer Seminar on approach to surgical infections

2. Presented by Tadele G/Michael Teklemuz Tsegay Modulator- Dr. Teklay Date -16-09-2016 E.C

3. SURGICAL INFECTIONS

4. Contents : Introduction Definition Types of surgical infections Definition and types of SSI

5. Introduction Surgical infections surgical wound itself or in other systems in the patient. They can be initiated not only by “damage” to the host but also by changes in the host’s physiologic state.

6. INFECTION Invasion of the body by pathogenic microorganisms and reaction of the host to organisms and their toxins

7. SURGICAL INFECTIONS Infections that require surgical treatment or related to operative interventions

8. A. Surgical Site Infection B. Soft Tissue Infection C. Body Cavity Infection D. Prosthetic Device related Infection TYPES OF SURGICAL INFECTION

9. Surgical site infection (SSI) 38% of all surgical infections Infection within 30 days of operation Classification: Superficial: Superficial SSI–infection 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

10. Cont --- 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.

11. Factors influencing SSIs Type of procedure Degree of contamination Duration of operation Urgency of operation skin preparation operating room environment Antibiotic prophylaxis

12. Local: High bacterial load Wound hematoma Necrotic tissue Foreign body Obesity Systemic: Advanced age Shock Diabetes Malnutrition Alcoholism Steroids Chemotherapy Immuno -compromise Patient Risk Factors

13. Cont --- Superficial Deep Organ/space

14. Prevention of SSI Pre-op: Treat pre-existing infection Improve general nutrition Shorter hospital stay Pre-op. shower Intraoperative: Antiseptic technique Surgical technique Post-operative: Hand hygiene

15. SOFT TISSUE INFECTIONS Cellulitis Inflammation of skin & subcutaneous tissue Non- suppurative Causative agents Staphylococci Cl. Perfringes Grams – ve organisms Strep. Pyogenes Common sites- limbs Affected area is red, hot & indurated

16. Clinical featu res Fever Tense shiny skin Toxic look DM pt may present with DKA Treatment : Rest, elevation of affected limb Penicillin, Erythromycin Fluocloxacillin ( staph. suspected )

17. NECROTIZING FASCIITIS Necrosis of superficial fascia, overlying skin Polymicrobial : Streptococci (90%), anaerobic Grampositive Cocci, aerobic Gram-negative Bacilli, and the Bacteroides spp. Sites- abd.wall (Meleny’s), perineum (Fournier’s), limbs, Usually follows abdominal surgery or trauma

18. Cont --- Diabetics more susceptible Starts as cellulitis, edema, systemic toxicity Appears less extensive than actual necrosis Investigation : Aspiration, Gram’s stain, CT, MRI Treatment : IV fluid, IV antibiotics (ampicillin, clindamycin l metronidazole, aminoglycosides ) Debridement , repeated dressings, skin grafting

19. GAS GANGRENE Cl. Perfringens, Cl. Septicum Exotoxins: lecithinase, collagenase, hyaluridase Large wounds of muscle ( contaminated by soil, foreign body ) Rapid myonecrosis, crepitus in subcutaneous tissue Seropurulent discharge, foul smell, swollen Toxemia, tachycardia, ill looking X-ray: gas in muscle and under skin Penicillin, clindamycin, metronidazole Wound exposure, debridement , drainage, amputation

20. STAPHYLCOCCAL INFECTIONS Abscess- localized pus collection Treatment- drainage, antibiotics Furuncle- infection of hair follicle / sweat glands Carbuncle- extension of furuncle into subcut. tissue common in diabetics common sites- back, back of neck Treatment: drainage, antibiotics, control diabetes

21. Body Cavity Infection Primary peritonitis: Spontaneous Children, Ascitic Haematogenous/ lymphatic route Antibiotic Secondary peritonitis: Inflam./ rupture of viscera Polymicrobial Investigations: blood, radiological Treatment of original cause

22. Escherichia coli Facultative anaerobe, Intestinal flora Produce exotoxin & endotoxin Endotoxin produce Gram-negative shock Wound infection, abdominal abscess, UTI, meningitis, endocarditis Treatment- ampicillin, cephalosporin, aminoglycoside

23. Pseudomonas aerobes, occurs on skin surface opportunistic pathogen may cause serious & lethal infection colonize ventilators, iv catheters, urinary catheters Wound infection, burn, septicemia Treatment: aminoglycosides , piperacillin , ceftazidime

24. PSEUDOMEMBRANOUS COLITIS Cl. Difficile Overtakes normal flora in patients on antibiotics Watery diarrhea, abdominal pain, fever Sigmoidoscopy: membrane of exudates (pseudomembranes) Stool- culture and toxin assay Treatment : stop offending antibiotic oral vancomycin/ metronidazole rehydration, isolate patient

25. CLOSTRIDIA Gram positive, anaerobe Rod shaped microorganisms Live in bowel & soil Produce exotoxin for pathogenicity Important members: Cl. Perfringens, Cl. Septicum ( gas gangrene ) Cl. Tetani ( tetanus ) Cl. Difficile ( pseudomembranous colitis )

26. GRAM NEGATVE ANAEROBES Bacteroides fragilis Normal flora in oral cavity, colon Intra-abdominal & gynecologic infections ( 90% ) Foul smelling pus, gas in surrounding tissue, necrosis Spiking fever, jaundice, Leukocytosis No growth on standard culture Needs anaerobe culture media Treatment: Surgical drainage Antibiotics- clindamycin, metronidazole

27. Prosthetic Device Related Infection Artificial valves and joints Peritoneal and haemodialysis catheters Vascular grafts Staphylococcus aureus Antibiotics, washing of prosthesis or removal

28. PROSTHETIC JOINT INFECTION(PJI ) Periprosthetic joint infection (PJI) is a unique clinical entity, markedly different from infections involving native bones or joints. Prosthetic joint infection (PJI), also referred to as periprosthetic infection, is infection involving the joint prosthesis and adjacent tissue PJI is characterized by a complex interplay between microbes, predominantly bacteria but occasionally fungi, and the host immune response. Only a minimal microbial burden is required to initiate a PJI.

29. Tsukayama classification early postoperative infection : onset within 1 st month of surgery 2) Late chronic infection : onset more than 1month of surgery ,insidious onset of symptoms 3) Acute hematogenous infection : onset more than 1month of surgery , acute onset of symptoms in previously well function prosthesis , distant source of infection 4) Positive intraoperative cultures : positive culture obtained at the time of revision for supposedly aseptic conditions.

30. Microorganism related factors: -Adequate dose -Virulence of microorganisms Host related factors: -Suitable environment ( closed space ) -Susceptible host Factors contributing to infections

31. Exotoxins: specific, soluble proteins, remote cytotoxic effect Cl.Tetani, Strep. pyogenes Endotoxins: part of gram-negative bacterial wall, lipopolysaccharides e.g., E coli Resist phagocytosis : Protective capsule Klebsiela and Strep. pneumoniae Pathogenicity of bacteria

32. Intact skin / mucous membrane. (surgery/ trauma- causes breach) Immunity: Cellular (phagocytes ) Antibodies Host Resistance

33. Local- pain, heat, redness, swelling, loss of function. (apparent in superficial infections) Systemic- fever, tachycardia, chills Clinical features

34. Principles of surgical treatment Debridement- necrotic, injured tissue Drainage- abscess, infected fluid Removal- infection source, foreign body Supportive measures: immobilization elevation antibiotics

35. HOST DEFENSE MECHANISMS Nonspecific Surface Mechanical barrier(skin, mucosa) Secretory barrier Immunoglobulins Ciliary motion Movement

36. Cont --- Specific Cellular defense Phagocytic cells Cell-mediated immunity (PNLs, eosinophils , mononuclear cells) (T lymphocytes & macrophages) Natural killer cells Humoral defense Lyzozyme Immunoglobulins Complement Interferon

37. Diagnosis • Redness • Swelling • Hyperthermia • Fluctuation • Purulent or turbid aspirate

38. CLASSIFICATION OF OPERATIVE WOUNDS CLEAN • Nontraumatic • No inflammation encountered • No break in technique • Respiratory, alimentary, genitourinary tracts not entered

39. Cont --- CLEAN CONTAMINATED • Gastrointestinal or respiratory tracts entered without significant spillage • Appendectomy • Oropharynx entered • Vagina entered • Genitourinary tract entered in absence of infected urine • Biliary tract entered in absence of infected bile • Minor break in technique

40. Cont --- CONTAMINATED • Major break in technique • Gross spillage from gastrointestinal tract • Traumatic wound, fresh • Entrance of genitourinary or biliary tracts in presence of infected urine or bile

41. Cont --- DIRTY and INFECTED • Acute bacterial inflammation encountered, without pus • Transection of clean tissue for the purpose of surgical access to a collection of pus • Traumatic wound with retained devitalized tissue,foreign bodies, fecal contamination, and/or delayed treatment, or from dirty source.

42. References Manipals of surgery 4 th edition UpToDate 21.6 Schwartez surgery 8 th edition Ayder surgery lecture note Bailey and love 28 th edition textbook of surgery

43. THANK YOU