1. Surgical Infections
Under supervision of :
Dr. MOHAMMED AL-AKEELY

2. infection
Invasion of the body by pathogenic microorganisms and reaction of the host to organisms and their toxins

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

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

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

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

7. Common organisms Gram positive bacteria: Streptococci Staphylococci
Clostridia
Gram negative bacteria:
Pseudomonas
E. coli
Bacteroid fragilis

8. Streptococcal infections
Cellulitis
Lymphangitis
Lymphadenitis
Necrotizing faciitis

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

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

11. cellulitis

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

13. Erysipelas

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

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

16. Lymphangitis

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

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

19. LYMPHADENITIS

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

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

22. Necrotizing fasciitis

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

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

25. Staphylococcal Infections

26. Clostridial infections
Gas gangrene
Tetanus
Pseudomembranous colitis

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

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

29. GAS GANGRENE

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

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

32. PSEUDOMEMBRANOUS COLITIS
Superinfection in patients in long term oral antibiotic therapy
Cl. Difficile
Watery diarrhea, abdominal pain, fever
Diagnosis needs Sigmoidoscopy, stool- culture and toxin assay
Treatment :
stop offending antibiotic
oral vancomycin/ metronidazole
rehydration, isolate patient

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

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

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

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

37. 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

38. Surgical site infection (SSI)
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.

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

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

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

42. TREATMENT Ab.with gram (-) spectrum -sulphamethoxasole -trimethoprim
-gentamycin
-ceprofloxacin
Check culture &sensitivity

43. pneumonia Rout of infection: or intubation. Pathogen includes
-gross aspiration during anesthesia
or intubation. Pathogen includes
anaerobic organism & gram(-)
bacilli.
- Atelectasis: the collapsed lung may become secondarily infected
-contiguous spread from another site.

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

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

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

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

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

49. antibiotics Chemotherapeutic agents that act on organisms
Bacteriocidal: Penicillin,Cephalosporin, Vancomycin, Aminoglycosides
Bacteriostatic: Erythromycin,Clindamycin,Tetracycline

50. COMMON ANTIBIOTICS Penicillins- penicillin G
Cephalosporins (II, III)-Cefruoxime, Ceftriaxone
Aminoglycosides- Gentamycin
Fluoroquinolones- Ciprofloxacin
Glycopeptides- Vancomycin
Macrolides- Erythromycin,
Tetracyclines-, Doxycycline

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

52. Wound Classification

53. Thank u