Surgical infections

SURGICAL SURGICAL INFECTIONINFECTION

Neil Mendoza, MD, FPSGS, FPCSNeil Mendoza, MD, FPSGS, FPCS

Factors that Increase the Factors that Increase the Number of Serious Surgical Number of Serious Surgical

InfectionInfection1.1. Performance of more complicated Performance of more complicated

and longer operationsand longer operations

2.2. Increase in the number of geriatric Increase in the number of geriatric patientspatients

3.3. Use of implantsUse of implants

4.4. Use of immunosuppressive agentsUse of immunosuppressive agents

Factors that Increase the Factors that Increase the Number of Serious Surgical Number of Serious Surgical

InfectionInfection5.5. Utilization of diagnostic and Utilization of diagnostic and

treatment modalitiestreatment modalities

6.6. Laxity of aseptic techniqueLaxity of aseptic technique

7.7. Disregard for established surgical Disregard for established surgical principlesprinciples

8.8. Unwarranted reliance upon Unwarranted reliance upon prophylactic antibiotic therapyprophylactic antibiotic therapy

Classification Of Surgical Classification Of Surgical InfectionsInfections

I. Relative to Final OutcomeI. Relative to Final Outcome1.1. Self limiting infections Self limiting infections

2.2. Serious infectionSerious infection

3.3. Fulminant infection (fatal or Fulminant infection (fatal or permanently disabling)permanently disabling)

Classification Of Surgical Classification Of Surgical InfectionsInfections

II. Relative to Time of OnsetII. Relative to Time of Onset1.1. Pre-operative surgical infectionPre-operative surgical infection

2.2. Operative surgical infectionOperative surgical infectiona. Preventable operative surgical a. Preventable operative surgical

infectioninfection

b. Non-preventable operative surgical b. Non-preventable operative surgical infectioninfection

3.3. Post-operative surgical infection Post-operative surgical infection (UTI, Respiratory, Wound)(UTI, Respiratory, Wound)

Determinants Of InfectionDeterminants Of Infection

A. Microbial Pathogenicity:A. Microbial Pathogenicity:1.1. Virulence (tissue invading powers)Virulence (tissue invading powers)

2.2. Infecting dose (10Infecting dose (1055))

3.3. Ability to produce toxins Ability to produce toxins (exotoxins / endotoxins)(exotoxins / endotoxins)

4.4. Ability to resist phagocytosis and Ability to resist phagocytosis and intracellular destructionintracellular destruction

B. Host Defenses:B. Host Defenses:1. Local Host defenses:1. Local Host defenses:

Layers of epitheliumLayers of epithelium Local environment featuresLocal environment features

Skin lack moistureSkin lack moisture Flushing action of tears & Flushing action of tears &

urineurine Cilia, peristalsis, mucus, pH Cilia, peristalsis, mucus, pH Local immunity IgALocal immunity IgA

B. Host Defenses:B. Host Defenses:2. Systemic Host defenses:2. Systemic Host defenses:

a.a. Decrease delivery of phagocytesDecrease delivery of phagocytes

1.1. Diminution in blood flowDiminution in blood flow

2.2. Presence of devitalized tissue, Presence of devitalized tissue, foreign bodies, hematomas and foreign bodies, hematomas and seromaseroma

3.3. Decrease vascular reactivity Decrease vascular reactivity (uremic, old age, high dose of (uremic, old age, high dose of steroid)steroid)

4.4. Decrease production of Decrease production of phagocytes (chemotherapy)phagocytes (chemotherapy)

2. Systemic Host defenses:2. Systemic Host defenses:

b.b. Abnormal serum factors (opsonins)Abnormal serum factors (opsonins) Specific antibody and complement act Specific antibody and complement act

as a strong opsonizing agents for as a strong opsonizing agents for phagocytosis of containing bacteria. phagocytosis of containing bacteria.

c.c. Abnormal ingestion & intracellular Abnormal ingestion & intracellular killing of Phagocyteskilling of Phagocytes Seen in uremia, ketosis, hyperglycemia, Seen in uremia, ketosis, hyperglycemia,

malignancies, severe thermal or malignancies, severe thermal or traumatic injury, malnutrition, traumatic injury, malnutrition, immunosuppresimmunosuppressedsed

c. Surgical technique:c. Surgical technique: Handle tissues gentlyHandle tissues gently Remove devitalized tissues, bloodRemove devitalized tissues, blood Using drainsUsing drains Avoid excessive cauteryAvoid excessive cautery (-) tension in intestinal anastomosis(-) tension in intestinal anastomosis Good blood supplyGood blood supply

Prevention Of InfectionPrevention Of Infection

A. Avoidance of Predisposing A. Avoidance of Predisposing ConditionsConditions

1. Bacterial Contamination:1. Bacterial Contamination: Minimize contamination ----> strict Minimize contamination ----> strict

aseptic techniqueaseptic technique 2 great sources of microbial 2 great sources of microbial

contaminationcontamination

a.a. ExogenousExogenous contact from breaks in contact from breaks in technique by the teamtechnique by the team

b.b. Endogenous Endogenous contamination from contamination from patient’s skin and various bacteria-patient’s skin and various bacteria-containing tracts.containing tracts.

Classification Of Surgical Wounds Classification Of Surgical Wounds According to Risk of InfectionAccording to Risk of Infection

a. CLEAN WOUND (I):a. CLEAN WOUND (I): 1.5 – 5.4% infection rates1.5 – 5.4% infection rates Elective cases, primarily closed Elective cases, primarily closed

and undrainedand undrained Nontraumatic, uninfected, no Nontraumatic, uninfected, no

inflammationinflammation No break in asepsisNo break in asepsis Respiratory, alimentary, Respiratory, alimentary,

genitourinary or oropharyngeal genitourinary or oropharyngeal tracts not enteredtracts not entered

Hernia repair, breast biopsyHernia repair, breast biopsy

B. CLEAN – CONTAMINATED WOUND:B. CLEAN – CONTAMINATED WOUND: 2.1 – 9.5% infection rate2.1 – 9.5% infection rate Alimentary, respiratory, genito-Alimentary, respiratory, genito-

urinary tract entered under urinary tract entered under controlled conditions and w/o controlled conditions and w/o unusual contaminationunusual contamination

Minor break in techniqueMinor break in technique Mechanical drainageMechanical drainage Appendectomy, biliary tractAppendectomy, biliary tract

C. CONTAMINATED WOUNDC. CONTAMINATED WOUND 3.4 – 13.2% infection rates3.4 – 13.2% infection rates Open, fresh traumatic woundOpen, fresh traumatic wound Gross spillage from gastrointestinal Gross spillage from gastrointestinal

tracttract Entrance of genitourinary or biliary Entrance of genitourinary or biliary

tracts in presence of infected urine tracts in presence of infected urine and bileand bile

Major break in techniqueMajor break in technique Penetrating abdominal trauma, large Penetrating abdominal trauma, large

tissue injury, enterotomy during bowel tissue injury, enterotomy during bowel obstructionobstruction

D. DIRTY AND INFECTED WOUNDD. DIRTY AND INFECTED WOUND 28 – 40% infection rates28 – 40% infection rates Traumatic wound with retained Traumatic wound with retained

devitalized tissue, foreign bodies, devitalized tissue, foreign bodies, fecal contamination or delayed fecal contamination or delayed treatmenttreatment

Perforated viscus encounteredPerforated viscus encountered Acute bacterial inflammation with Acute bacterial inflammation with

pus encountered during operationpus encountered during operation

Prophylaxis: Prevent Prophylaxis: Prevent Wound InfectionsWound Infections

1. Avoidance of Bacterial Contamination:1. Avoidance of Bacterial Contamination:

a) Environmental factorsa) Environmental factors Avoid exogenous and endogenous Avoid exogenous and endogenous

contaminationcontamination Use of ultraviolet light and laminar flow Use of ultraviolet light and laminar flow

ventilationventilation Limitation of traffic in and out of the Limitation of traffic in and out of the

operating roomoperating room Limitation of activity and talking within Limitation of activity and talking within

the operating roomthe operating room

b) b) Pre-operative preparations of the Pre-operative preparations of the patientpatient

Pre-operative shower w/ Pre-operative shower w/ antimicrobial soap (chlorhexidine)antimicrobial soap (chlorhexidine)

Cutaneous infection should be Cutaneous infection should be controlled or cleared before controlled or cleared before elective operationelective operation

Hair removalHair removal promotes bacterial growth to 100% if promotes bacterial growth to 100% if

the blade cuts the skinthe blade cuts the skin Seropian & Reynolds study 406 clean Seropian & Reynolds study 406 clean

wounds showed that shaving wounds showed that shaving increases infection rate to 5.6% from increases infection rate to 5.6% from 0.6% where no shaving was done0.6% where no shaving was done

c.) Skin preparationc.) Skin preparation Scrub the operative area for 5 to 7 Scrub the operative area for 5 to 7

mins. germicidal solution and paint mins. germicidal solution and paint w/ povidine-iodine or chlorhexidinew/ povidine-iodine or chlorhexidine

Use an antimicrobial incision drapeUse an antimicrobial incision drape

1.1. Operating Room Team and Operating Room Team and DisciplineDiscipline

Wear clean scrab suits, cap and maskWear clean scrab suits, cap and mask Scrub hands and forearms w/ antimicrobial soapScrub hands and forearms w/ antimicrobial soap Careful wearing of gowns and glovesCareful wearing of gowns and gloves Change puncture or tear glovesChange puncture or tear gloves

Operating Room Team and DisciplineOperating Room Team and Discipline

Wear clean scrab suits, cap and maskWear clean scrab suits, cap and mask

Scrub hands and forearms w/ Scrub hands and forearms w/ antimicrobial soapantimicrobial soap

Careful wearing of gowns and glovesCareful wearing of gowns and gloves

Change puncture or tear glovesChange puncture or tear gloves

3. Endogenous Contamination3. Endogenous Contamination Avoid bacterial contamination of the Avoid bacterial contamination of the

surgical wound at the time of surgical wound at the time of transection of the GIT, GUT and transection of the GIT, GUT and respiratory tractrespiratory tract

4. Importance of Surgical Technique4. Importance of Surgical Technique Gentle care of the tissues to minimized Gentle care of the tissues to minimized

local damagedlocal damaged All devitalized tissue and foreign bodies All devitalized tissue and foreign bodies

should be removedshould be removed Use monofilament sutures for potentially Use monofilament sutures for potentially

infected woundinfected wound Avoid the presence of hematomas, Avoid the presence of hematomas,

seromas and dead spacesseromas and dead spaces Role of delayed primary closure (tertiary Role of delayed primary closure (tertiary

wound healing)wound healing)

5. Systemic Factors:5. Systemic Factors: Host resistance (control systemic Host resistance (control systemic

diseases)diseases) Correct malnutritionCorrect malnutrition Avoid disturbance of circulationAvoid disturbance of circulation Avoid unnecessary used of drugsAvoid unnecessary used of drugs

6. Systemic Prophylactic 6. Systemic Prophylactic Chemotherapeutic and Antibiotic:Chemotherapeutic and Antibiotic:

Avoid indiscriminate used of Avoid indiscriminate used of antibiotics because:antibiotics because:

i.i. Secondary infection or superimposed Secondary infection or superimposed infectioninfection

ii.ii. Hypersensitivity reactionHypersensitivity reaction

iii.iii. May mask signs and symptoms of infectionMay mask signs and symptoms of infection

iv.iv. Development of antibiotic resistant strainsDevelopment of antibiotic resistant strains

7. Reduction of Colonic Bacteria 7. Reduction of Colonic Bacteria (Intestinal Antisepsis)(Intestinal Antisepsis)

reduce the high rate of infectious reduce the high rate of infectious complication after colorectal surgerycomplication after colorectal surgery

Combined w/ mechanical cleansing Combined w/ mechanical cleansing of the colonof the colon

Ideal drugs:Ideal drugs:1.1. BactericidalBactericidal

2.2. Minimillay absorbedMinimillay absorbed

3.3. No side effectNo side effect

Types:Types:a. 3 day bowel preparationa. 3 day bowel preparationb. Nichols-Condon Methodb. Nichols-Condon Method

2 days fluid diet, mechanical 2 days fluid diet, mechanical Oral methronidazole and erythromycin Oral methronidazole and erythromycin

1gm each 1gm each 1 gm give 1, 2 qnd 11 PM1 gm give 1, 2 qnd 11 PM

c. Whole GUT irrigation w/ polyethylene-c. Whole GUT irrigation w/ polyethylene-glycol-electrolyte lavage (GOLYTELY) 1 L glycol-electrolyte lavage (GOLYTELY) 1 L ---> 5hrs---> 5hrs

w/o = wound infection 48%w/o = wound infection 48% w/ = wound infection 20%w/ = wound infection 20%

8. Prophylactic Antibiotics:8. Prophylactic Antibiotics: Given IV 30 – 60 mins before operation Given IV 30 – 60 mins before operation

so that adequate blood and tissue so that adequate blood and tissue levels are present at the time that the levels are present at the time that the skin incision is madeskin incision is made

Another dose given if operating time is Another dose given if operating time is > 4hrs and other dose given w/in 24 > 4hrs and other dose given w/in 24 hrs.hrs.

Prophylactic Antibiotics:Prophylactic Antibiotics: Principles:Principles:

1.1. Choose antibiotic effective against Choose antibiotic effective against pathogens most likely to be pathogens most likely to be encounteredencountered

2.2. Low toxicityLow toxicity

3.3. Administer a single full therapeutic Administer a single full therapeutic dose. 2dose. 2ndnd dose given postoperatively dose given postoperatively

4.4. Utilization of host defenses to augment Utilization of host defenses to augment antimicrobial effect of the antibioticsantimicrobial effect of the antibiotics

Prevention Of InfectionPrevention Of Infection

Avoidance of Predisposing Avoidance of Predisposing ConditionsConditions

Immunotherapy:Immunotherapy: Specific immunotherapy in the Specific immunotherapy in the

practice of surgery is limited to practice of surgery is limited to the administration of antitoxins the administration of antitoxins against:against:1.1. TETANUSTETANUS

2.2. RABIESRABIES

3.3. SNAKE BITESNAKE BITE

Surgical Site InfectionsSurgical Site Infections SSIs are infections of the tissues, SSIs are infections of the tissues,

organs, or spaces exposed by organs, or spaces exposed by surgeons during performance of an surgeons during performance of an invasive procedure.invasive procedure.

SSIs are classified into SSIs are classified into

1.1. Incisional:Incisional:

a.a. superficial (limited to skin and superficial (limited to skin and subcutaneous tissue)subcutaneous tissue)

b.b. deep incisional categories deep incisional categories

2.2. Organ/space infectionsOrgan/space infections

Factors: Factors: 1. The degree of microbial contamination 1. The degree of microbial contamination

of the wound during surgeryof the wound during surgery

2. The duration of the procedure 2. The duration of the procedure

3. Host factors such as diabetes, 3. Host factors such as diabetes, malnutrition, obesity, immune malnutrition, obesity, immune suppression, and a number of other suppression, and a number of other underlying disease states.underlying disease states.

Risk Factors for Development Risk Factors for Development of Surgical Site Infectionsof Surgical Site Infections

A. Patient factors

1. Older age2. Immunosuppressi

on3. Obesity4. Diabetes mellitus5. Chronic

inflammatory process

6. Malnutrition

7. Peripheral vascular disease8. Anemia9. Radiation10. Chronic skin disease11. Carrier state (e.g., chronic Staphylococcus carriage) 12.Recent operation


B. Local factors

1. Poor skin preparation2. Contamination of instruments3. Inadequate antibiotic prophylaxis4. Prolonged procedure5. Local tissue necrosis6. Hypoxia, hypothermia


C. Microbial factors

1. Prolonged hospitalization (leading to nosocomial organisms)

2. Toxin secretion 3. Resistance to clearance (e.g., capsule

formation)

Surgical management of the wound Surgical management of the wound

In healthy individuals, In healthy individuals, class I and II class I and II wounds wounds may be may be closed primarilyclosed primarily, while , while skin closure of class III and IV wounds is skin closure of class III and IV wounds is associated with high rates of incisional associated with high rates of incisional SSIs (25 to 50%).SSIs (25 to 50%).

Class III and IV wounds Class III and IV wounds should be packed should be packed open and allowed to open and allowed to heal by secondary heal by secondary intentionintention, although selective use of , although selective use of delayed primary closure delayed primary closure has been has been associated with a reduction in incisional associated with a reduction in incisional SSI rates.SSI rates.

Surgical management of the Surgical management of the wound wound

Increased SSI rates being Increased SSI rates being associated with hyperglycemiaassociated with hyperglycemia

It is recommended that clinicians It is recommended that clinicians maintain appropriate blood sugar maintain appropriate blood sugar control in diabetic patients in the control in diabetic patients in the peri-operative period to minimize peri-operative period to minimize the occurrence of SSIs.the occurrence of SSIs.

ANTIBIOTICSANTIBIOTICS

A chemical cpd. derived from or A chemical cpd. derived from or produced by living organisms produced by living organisms capable at low concentration of capable at low concentration of inhibiting the life process of the inhibiting the life process of the microorganismsmicroorganisms

ANTIBIOTICSANTIBIOTICSClassification:Classification:

1.1. Bacteriostatic: Bacteriostatic: prevent the growth of bacteria but do prevent the growth of bacteria but do

not destroy them. Affects early stages not destroy them. Affects early stages of protein synthesis in the ribosomeof protein synthesis in the ribosome

2.2. Bactericidal:Bactericidal: Agents that actively kill the bacteriaAgents that actively kill the bacteria It causes the ribosome to miscode and It causes the ribosome to miscode and

consequently induced the consequently induced the manufacture of defective proteins and manufacture of defective proteins and enzymes that poison the cellenzymes that poison the cell

Antibiotic Mode of ActionAntibiotic Mode of Action

Cellular site of Cellular site of inhibitioninhibition

BactericidalBactericidal BacteriostatiBacteriostaticc

1. 1. Cell wall Cell wall

synthesissynthesisPenicillinPenicillin

CephalosphorCephalosphorinin

VancomysinVancomysin

BacitracinBacitracin

2. 2. Barrier Barrier function function

of cell of cell

membranemembrane

Polymyxin BPolymyxin B

ColistinColistin

Amphotericin Amphotericin BB

NystatinNystatin

Antibiotic Mode of ActionAntibiotic Mode of Action

Cellular site of Cellular site of inhibitioninhibition

BactericidalBactericidal BacteriostaticBacteriostatic

3. Protein 3. Protein synthesis in synthesis in the ribosomethe ribosome

StreptomycinStreptomycin

aminoglycosidaminoglycosidee

TetracyclinTetracyclin

ChloramphenicoChloramphenicoll

ErythromycinErythromycin

ClindamycinClindamycin

4. DNA replication 4. DNA replication

in chromosomein chromosomegriseogulvingriseogulvin

Antibiotic AgentsAntibiotic Agents

1. Penicillin1. Penicillin blocks the synthesis of the blocks the synthesis of the

bacterial wall ---> osmotic bacterial wall ---> osmotic instability & lysisinstability & lysis

Active against most gram (+) Active against most gram (+) bacteriabacteria

2. Cephalosphorin2. Cephalosphorin Bactericidal by inhibiting bacterial Bactericidal by inhibiting bacterial

cell wall synthesiscell wall synthesis Arranged into generationArranged into generation For gram (+) and (-) bacteriaFor gram (+) and (-) bacteria


3.Erythromycin3.Erythromycin Bacteriostatic ; bactericidal in Bacteriostatic ; bactericidal in

higher dosehigher dose

Inhibit bacterial protein synthesisInhibit bacterial protein synthesis

Treatment of choice in treating Treatment of choice in treating mycoplasm and Legionnaire’s mycoplasm and Legionnaire’s disease, also for actinomycosisdisease, also for actinomycosis


4. Tetracyclines4. Tetracyclines For gram (+) and (-) not sensitive For gram (+) and (-) not sensitive

to penicillinto penicillin Good for TBGood for TB BacteriostaticBacteriostatic Interfere w/ protein synthesisInterfere w/ protein synthesis For actinomycosis and nocardiosisFor actinomycosis and nocardiosis Should be avoided in early Should be avoided in early

childhood causing yellow childhood causing yellow discoloration of the teethdiscoloration of the teeth


5. Chloramphenicol5. Chloramphenicol Broad spectrum and bacteriostaticBroad spectrum and bacteriostatic Inhibits protein synthesisInhibits protein synthesis Well absorbed orally and Well absorbed orally and

parenterallyparenterally Drug of choice in typhoid fever Drug of choice in typhoid fever

and other salmonella infectionand other salmonella infection Good for meningitis and H. Good for meningitis and H.

influenzaeinfluenzae


6. Aminoglycoside6. Aminoglycoside BactericidalBactericidal For gm(-) and (+) and For gm(-) and (+) and

mycobacteriamycobacteria Toxic side effects:Toxic side effects:

Auditory branch damageAuditory branch damage nephrotoxicnephrotoxic

AntibioticAntibiotic Agents Agents

7. Metronidazole7. Metronidazole BactericidalBactericidal Important for obligate anaerobic Important for obligate anaerobic

bacteriabacteria

8. Amphotericin B8. Amphotericin B Good for antifungal agentsGood for antifungal agents IV, intrathecally or instilled IV, intrathecally or instilled

directly to the site of infectiondirectly to the site of infection


9. Sulfonamides - Trimethoprim9. Sulfonamides - Trimethoprim Effective against community acquired Effective against community acquired

gm (-)gm (-) Orally administeredOrally administered Has limited usefulnes in nosocomial Has limited usefulnes in nosocomial

infectioninfection

10. 4-Fluoroquinolones10. 4-Fluoroquinolones Good for nosocomial infectionsGood for nosocomial infections Good activity against nearly all gram (-) Good activity against nearly all gram (-)

organismorganism


11. Carbapenems11. Carbapenems Has the widest spectrumHas the widest spectrum Highly effective against most Highly effective against most

aerobic (S. aureus & P. aeruginosa) aerobic (S. aureus & P. aeruginosa) as well as anaerobic bacteriaas well as anaerobic bacteria

Diagnosis and Treatment of Diagnosis and Treatment of Surgical InfectionSurgical Infection

The most important part of the The most important part of the evaluation of pt. suspected of having a evaluation of pt. suspected of having a surgical infection is careful surgical infection is careful history and history and PEPE

Laboratory and radiological technique:Laboratory and radiological technique: Urinalysis, CBC, blood culture and Urinalysis, CBC, blood culture and

sensitivitysensitivity Ultrasonography / CT scan / MRIUltrasonography / CT scan / MRI

Diagnosis and Treatment of Diagnosis and Treatment of Surgical InfectionSurgical Infection

If w/ Pus (color, Odor and If w/ Pus (color, Odor and Consistency)Consistency) Foul odorFoul odor -- AnaerobicAnaerobic GreenishGreenish -- P. aeruginosaP. aeruginosa CreamyCreamy -- S. aureusS. aureus Thin wateryThin watery - Strep / clostridium- Strep / clostridium

Surgical InterventionSurgical Intervention

Primary principle of surgical Primary principle of surgical treatment of surgical infection treatment of surgical infection are:are:

1.1. Incision and drain of localized abscessIncision and drain of localized abscess

2.2. Adequate debridement of necrotic Adequate debridement of necrotic tisuetisue

3.3. Removal of all hematomas, seroma Removal of all hematomas, seroma and foreign bodiesand foreign bodies

4.4. If with dead space ---> put sterile If with dead space ---> put sterile close suction tubeclose suction tube

Types of Surgical InfectionsTypes of Surgical Infections

I.I. Soft Tissue Infections:Soft Tissue Infections:A.A. Cellulitis, Erysipelas, LymhangitisCellulitis, Erysipelas, Lymhangitis

Erythema, local pain & tenderness, edemaErythema, local pain & tenderness, edema Fever, chills, malaise and toxic reactionFever, chills, malaise and toxic reaction Pathogens:Pathogens:

1.1. S. pyogenesS. pyogenes

2.2. S. aureusS. aureus

3.3. S. pneumoniaeS. pneumoniae

4.4. H. influenzaeH. influenzae

5.5. Aerobic and anaerobic gram (-)Aerobic and anaerobic gram (-) Tx: - antibiotic, immobilization / Tx: - antibiotic, immobilization /

elevation and hygieneelevation and hygiene


I.I. Soft Tissue Infections:Soft Tissue Infections:A.A. Cellulitis, Erysipelas, Cellulitis, Erysipelas,

LymhangitisLymhangitis


I.I. Soft Tissue Soft Tissue Infections:Infections:

B.B. Soft tissue Soft tissue abscessabscess

Furunculosis, felon, Furunculosis, felon, carbunclecarbuncle

Tx: - incision and Tx: - incision and drainagedrainage

- antibioticantibiotic

- hygiene and - hygiene and nutritionnutrition

CarbuncleCarbuncle


I.I. Soft Tissue Infections:Soft Tissue Infections:C.C. Necrotizing Soft Tissue Infections:Necrotizing Soft Tissue Infections:

Necrotizing fascitis, strep. Necrotizing fascitis, strep. Gangrene, gas gangrene, Gangrene, gas gangrene, bacterial synergistic gangrene, bacterial synergistic gangrene, clostridium myonecrosis and clostridium myonecrosis and Fournier’s gangreneFournier’s gangrene

Mixed aerobic and anaerobic Mixed aerobic and anaerobic gram negative and gram gram negative and gram positive bacteria as well as positive bacteria as well as fungifungi

Patients at risk; elderly, Patients at risk; elderly, immunosuppressed, or diabetic; immunosuppressed, or diabetic; peripheral vascular disease; or those peripheral vascular disease; or those with a combination of these factors. with a combination of these factors.

common among these host factors:common among these host factors:

compromise of the fascial blood compromise of the fascial blood supply to some degree, coupled with supply to some degree, coupled with the introduction of exogenous the introduction of exogenous microbes microbes

most commonly affected: most commonly affected: extremities, extremities, perineum, trunk, and torso perineum, trunk, and torso

Necrotizing fascitisNecrotizing fascitis

Manifestations:Manifestations:1. small break or sinus in the skin from 1. small break or sinus in the skin from

which grayish, turbid semipurulent which grayish, turbid semipurulent material ("dishwater pus") can be material ("dishwater pus") can be expressedexpressed

2. skin changes (bronze hue or brawny 2. skin changes (bronze hue or brawny induration), blebs, or crepitusinduration), blebs, or crepitus

3. pain at the site of infection that appears 3. pain at the site of infection that appears to be out of proportion to any of the to be out of proportion to any of the physical manifestationsphysical manifestations

4. sepsis syndrome or septic shock4. sepsis syndrome or septic shock

Treatment:Treatment: Debridement of all necrotic tissue Debridement of all necrotic tissue

(amputation)(amputation) Reconstruction done once infection is Reconstruction done once infection is

controlledcontrolled

Treatment:Treatment: Antimicrobial agents directed Antimicrobial agents directed

against gram-positive and gram-against gram-positive and gram-negative aerobes and anaerobes negative aerobes and anaerobes (e.g., vancomycin plus a (e.g., vancomycin plus a carbapenem), as well as high-dose carbapenem), as well as high-dose aqueous penicillin G (16,000 to aqueous penicillin G (16,000 to 20,000 U/d for clostridial pathogens 20,000 U/d for clostridial pathogens

Antibiotic therapy can be refined Antibiotic therapy can be refined based on culture and sensitivity based on culture and sensitivity results, particularly in the case of results, particularly in the case of monomicrobial soft tissue infections.monomicrobial soft tissue infections.

D. TetanusD. Tetanus Clostridium tetany:Clostridium tetany:

o TetanospasmTetanospasm – acts on the anterior – acts on the anterior horn cells of spinal cord and brain horn cells of spinal cord and brain stem by blocking the inhibitor stem by blocking the inhibitor synapsessynapses

o Tetanolysin Tetanolysin - cardiotoxic and - cardiotoxic and hemolysishemolysis

Sx:Sx:o Restlessness , headache, stiff neck, Restlessness , headache, stiff neck,

difficulty of swallowingdifficulty of swallowingo Orthotonus, opisthotonus, Orthotonus, opisthotonus,

convulsionconvulsion

TetanusTetanusTx:Tx: Tetanus immune globulin (TIG) 500 Tetanus immune globulin (TIG) 500

to 10,000 units and tetanus toxoidto 10,000 units and tetanus toxoid Intensive unit: - sedation, Intensive unit: - sedation,

respirator if needed, good nursing respirator if needed, good nursing care, quite roomcare, quite room

Wound debridement Wound debridement Penicillin G NaPenicillin G Na Muscle relaxant, analgesic, Muscle relaxant, analgesic,

adequate nutrition, laxatives, adequate nutrition, laxatives, pressure sore precautions, eye pressure sore precautions, eye protectionprotection

II. Body Cavity Infections:II. Body Cavity Infections:

A.A. Peritonitis and Intra-abdominal abscessPeritonitis and Intra-abdominal abscess

1.1. Primary peritonitisPrimary peritonitis Single organism, in children and adultSingle organism, in children and adult microbes invade the normally sterile microbes invade the normally sterile

confines of the peritoneal cavity via confines of the peritoneal cavity via hematogenous dissemination from a hematogenous dissemination from a distant source of infection or direct distant source of infection or direct inoculationinoculation

more common among patients with more common among patients with ascites and individuals being treated ascites and individuals being treated for renal failure via peritoneal dialysisfor renal failure via peritoneal dialysis

Tx: antibioticTx: antibiotic

Primary peritonitisPrimary peritonitis Diagnosis is established based on Diagnosis is established based on

identification of risk factors identification of risk factors

a. physical examination: diffuse a. physical examination: diffuse tenderness and guarding without tenderness and guarding without localized findingslocalized findings

b. absence of pneumoperitoneum on b. absence of pneumoperitoneum on abdominal flat plate and upright abdominal flat plate and upright roentgenogramsroentgenograms

c. more than 100 WBCs/mL, and c. more than 100 WBCs/mL, and microbes with a single morphology microbes with a single morphology on Gram's stain performed on fluid on Gram's stain performed on fluid obtained via paracentesisobtained via paracentesis

Primary peritonitisPrimary peritonitisTreatment :Treatment :

a. Administration of an antibiotic to a. Administration of an antibiotic to which the organism is sensitive; which the organism is sensitive; often 14 to 21 days of therapy are often 14 to 21 days of therapy are required. required.

b. Removal of indwelling devices (e.g., b. Removal of indwelling devices (e.g., peritoneal dialysis catheter or peritoneal dialysis catheter or peritoneovenous shunt) may be peritoneovenous shunt) may be required for effective therapy of required for effective therapy of recurrent infections.recurrent infections.

2. Secondary bacterial peritonitis2. Secondary bacterial peritonitis secondary to perforation or rupture secondary to perforation or rupture

of a hollow viscusof a hollow viscus

Ruptured AP, perforated duodenal Ruptured AP, perforated duodenal ulcer, complicated diverticular ulcer, complicated diverticular disease, etcdisease, etc

Secondary bacterial peritonitisSecondary bacterial peritonitis combination of antibiotic agents or single combination of antibiotic agents or single

agents with a broad spectrum of activity agents with a broad spectrum of activity can be usedcan be used

conversion of a parenteral to an oral conversion of a parenteral to an oral regimen only when the patient's ileus regimen only when the patient's ileus resolvesresolves

Effective source control and antibiotic Effective source control and antibiotic therapy therapy is associated with low failure rates is associated with low failure rates and a mortality rate of approximately 5 to and a mortality rate of approximately 5 to 6%; inability to control the source of 6%; inability to control the source of infection leads to mortality greater than infection leads to mortality greater than 40%. 40%.

Secondary bacterial peritonitisSecondary bacterial peritonitis

Treatment:Treatment:

surgical intervention and antibioticeffective therapy requires source

control:a. remove the diseased organ b. débridement of necrotic,

infected tissue and debris c. administration of antimicrobial

agents directed against aerobes and anaerobes

Secondary bacterial peritonitisSecondary bacterial peritonitisDiagnosis & Treatment:Diagnosis & Treatment: computed tomographic (CT) scan- best computed tomographic (CT) scan- best percutaneous drainage under imagingpercutaneous drainage under imaging Surgical intervention:Surgical intervention:

1.1. Multiple abscesses Multiple abscesses

2.2. Abscesses in proximity to vital Abscesses in proximity to vital structures such that percutaneous structures such that percutaneous drainage would be hazardous, and drainage would be hazardous, and

3.3. Those in whom an ongoing source of Those in whom an ongoing source of contamination (e.g., enteric leak) is contamination (e.g., enteric leak) is identified.identified.

Secondary bacterial peritonitisSecondary bacterial peritonitis

Treatment:Treatment: antibiotics with aerobic and anaerobic antibiotics with aerobic and anaerobic

activity activity drainage catheter in situ until:drainage catheter in situ until:

a.a. it is clear that cavity collapse has it is clear that cavity collapse has occurred, occurred,

b.b. output is less than 10 to 20 mL/d, output is less than 10 to 20 mL/d,

c.c. no evidence of an ongoing source of no evidence of an ongoing source of contamination is present contamination is present

d.d. patient's clinical condition has patient's clinical condition has improved. improved.

3. Tertiary peritonitis3. Tertiary peritonitis poorly understood poorly understood more common in immunosuppressed more common in immunosuppressed

patients in whom peritoneal host patients in whom peritoneal host defenses do not effectively clear or defenses do not effectively clear or sequester the initial secondary sequester the initial secondary microbial peritoneal infectionmicrobial peritoneal infection

associated with mortality rates in associated with mortality rates in excess of 50%excess of 50%


III. Prosthetic Device – Associated III. Prosthetic Device – Associated InfectionsInfections

Frequently eradicated after removal Frequently eradicated after removal of the foreign bodyof the foreign body

IV. Hospital – Acquired InfectionIV. Hospital – Acquired Infection

1.1. Wound infectionWound infection

2.2. Urinary tract infection (most Urinary tract infection (most common)common)

3.3. Lower respiratory tract infectionLower respiratory tract infection

4.4. Vascular catheter-related infectionVascular catheter-related infection

NOSOCOMIAL INFECTIONNOSOCOMIAL INFECTION related to prolonged use of indwelling related to prolonged use of indwelling

tubes and catheters for the purpose tubes and catheters for the purpose of urinary drainage, ventilation, and of urinary drainage, ventilation, and venous and arterial access, venous and arterial access, respectively.respectively.

a. UTI: a. UTI: Treatment for 10 to 14 days with a Treatment for 10 to 14 days with a

single antibiotic. single antibiotic. indwelling urinary catheters indwelling urinary catheters

removed as quickly as possibleremoved as quickly as possible

b. Mechanical Ventilator: b. Mechanical Ventilator: associated with an increased associated with an increased

incidence of pneumoniaincidence of pneumonia Diagnosis: X-ray evidence of one or Diagnosis: X-ray evidence of one or

more areas of pulmonary more areas of pulmonary consolidation.consolidation.

broncho-alveolar lavage to obtain broncho-alveolar lavage to obtain samples; Gram's stain & culture to samples; Gram's stain & culture to assess for the presence of microbes. assess for the presence of microbes.

Surgical patients should be weaned Surgical patients should be weaned from mechanical ventilation as soon as from mechanical ventilation as soon as feasible, based on oxygenation and feasible, based on oxygenation and inspiratory effort.inspiratory effort.

c. Intravascular catheter:c. Intravascular catheter:

Increase the risk of infectionIncrease the risk of infection1.1. Prolonged insertionProlonged insertion

2.2. Insertion under emergency Insertion under emergency conditionsconditions

3.3. Manipulation under nonsterile Manipulation under nonsterile conditionsconditions

4.4. use of multilumen cathetersuse of multilumen catheters

ASEPSIS ASEPSIS and and

ANTISEPSISANTISEPSIS

Surgical Asepsis:Surgical Asepsis: Prevention of the access of Prevention of the access of

microorganisms to an operative microorganisms to an operative woundwound

Destroy and remove bacteria and Destroy and remove bacteria and other pathogens from all objects other pathogens from all objects coming in contact with the woundcoming in contact with the wound

NEW:NEW:

1.1. Surgical isolators cemented to Surgical isolators cemented to operative siteoperative site

2.2. Use of laminar flowUse of laminar flow

TERMSTERMS

1. Antiseptic:1. Antiseptic: Chemical agents that either kills Chemical agents that either kills

or inhibits the growth of bacteria or inhibits the growth of bacteria and applied to human tissuesand applied to human tissues

2. Disinfectant:2. Disinfectant: Germicidals applied to inanimate Germicidals applied to inanimate

objectsobjects

3. Sterilization:3. Sterilization: A process of killing all A process of killing all

microorganismmicroorganism

ASEPTIC TECHNIQUEASEPTIC TECHNIQUE Hygienic hand washingHygienic hand washing Pre-operative preparation of the Pre-operative preparation of the

patient’s skinpatient’s skin Use of sterile gloves and gown as well Use of sterile gloves and gown as well

as application of sterile drapes to as application of sterile drapes to operative sitesoperative sites

Isolation precautionIsolation precaution Sterilization, with autoclave or other Sterilization, with autoclave or other

method, of instrument that will be method, of instrument that will be used.used.

Proper waste disposalProper waste disposal

OPERATING ROOMOPERATING ROOM Ideally, free from bacterial contaminationIdeally, free from bacterial contamination 20 x 20 ft recommended size20 x 20 ft recommended size

1.1. Area for gowning of operative teamArea for gowning of operative team2.2. Room for additional materials neededRoom for additional materials needed

Appropriate ventilation:Appropriate ventilation: Laminar flow (ideal)Laminar flow (ideal) Air passes through a filter that Air passes through a filter that

efficiently removes bacteria and fungi efficiently removes bacteria and fungi but not virusesbut not viruses

Doors should remain closed except as Doors should remain closed except as neededneeded

Pressure in the OR should be positive Pressure in the OR should be positive relative to outsiderelative to outside

Minimize personnel inside the roomMinimize personnel inside the room

PATIENTPATIENT The most common source of The most common source of

contamination in the ORcontamination in the OR Preparation of patient’s skin:Preparation of patient’s skin:

1.1. Preoperative showeringPreoperative showering2.2. Hair removal, only at operative sites, Hair removal, only at operative sites,

done in the ORdone in the OR3.3. Application of antiseptic (Povidone Application of antiseptic (Povidone

iodine – active to bacteria, fungi and iodine – active to bacteria, fungi and viruses) to patient’s skin viruses) to patient’s skin

4.4. Application of Application of sterile drapessterile drapes

PATIENTPATIENT

Factors associated w/ increased infection Factors associated w/ increased infection rates:rates:

AgeAge

ObesityObesity

Diabetes mellitusDiabetes mellitus

CirrhosisCirrhosis

UremiaUremia

Connective tissue disordersConnective tissue disorders

Hereditary or induced Hereditary or induced immunodeficiency stateimmunodeficiency state

NutritionNutrition

OR TeamOR Team1.1. Minimize the number of people inside the Minimize the number of people inside the

roomroom

2.2. Proper scrubbing and attire Proper scrubbing and attire

3.3. Sterile gloves and gownSterile gloves and gown Gloves protect the patient from the Gloves protect the patient from the

hands of the surgeonhands of the surgeon Gloves protect the doctor from Gloves protect the doctor from

contaminated blood/body fluids contaminated blood/body fluids Punctured gloves:Punctured gloves:

50-70% frequency50-70% frequency Non-dominant index finger is the most Non-dominant index finger is the most

common site of perforationcommon site of perforation 90% of perforation if surgery last for 90% of perforation if surgery last for

> 2 hrs.> 2 hrs.

OR TeamOR Team

3. Sterile gloves and gown3. Sterile gloves and gown Ideal gown:Ideal gown:

Should be impermeable to moistureShould be impermeable to moisture

1. Single layer gown --> < 2hrs operation 1. Single layer gown --> < 2hrs operation or or

<100 ml of blood<100 ml of blood

2. Reinforced gown --> 2-4 hrs or 100-2. Reinforced gown --> 2-4 hrs or 100-500ml 500ml

of bloodof blood

3. Plastic reinforced --> > 4hrs or > 500ml 3. Plastic reinforced --> > 4hrs or > 500ml of of

blood lossblood loss

STERILIZATIONSTERILIZATION

1.1. Steam Under Steam Under Pressure Pressure (Autoclave)(Autoclave)

Most reliable, Most reliable, power of power of penetration, easy penetration, easy to control and to control and economicaleconomical

Steam----Steam---->Condense----> >Condense----> Produce heatProduce heat

15psi for 15 to 45 15psi for 15 to 45 min = 121 Cmin = 121 C

2. Dry Heat Sterilization:2. Dry Heat Sterilization: Used for:Used for: a. glasswarea. glassware

b. talc, vaseline, b. talc, vaseline, fats and oilsfats and oils

Bake the material in hot air ovenBake the material in hot air oven 121 C (250 F) = 6 hrs.121 C (250 F) = 6 hrs. 170 C (340 F) = 1 hr.170 C (340 F) = 1 hr.

3. Gas Sterilization:3. Gas Sterilization: Ethylene oxideEthylene oxide Uses a chamber where temp and humidity Uses a chamber where temp and humidity

is controlled and air can be evacuatedis controlled and air can be evacuated 3 – 6 hrs3 – 6 hrs Use: (for delicate instruments) – optical Use: (for delicate instruments) – optical

lenses, tubings and plastic parts of heart-lenses, tubings and plastic parts of heart-lung machine and respiratorslung machine and respirators

STERILIZATIONSTERILIZATION

4. Radiation Sterilization:4. Radiation Sterilization: Cobalt 60Cobalt 60 For heat sensitive materials (drugs)For heat sensitive materials (drugs)

5. Chemical Sterilization:5. Chemical Sterilization: 2% glutaraldehyde ----> cidex / 2% glutaraldehyde ----> cidex /

sonacidesonacide Bactericidal, sporocidal and Bactericidal, sporocidal and

virucidalvirucidal

De-germing the SkinDe-germing the Skin

Antiseptics are also admixed Antiseptics are also admixed with soapwith soap

Vigorous scrubbing with soap Vigorous scrubbing with soap containing:containing:

1. Hexachlorophene1. Hexachlorophene

2. Iodophors2. Iodophors

3. Chlorhexidine gluconate3. Chlorhexidine gluconate

1. Hexachlorophene1. Hexachlorophene BisphenolBisphenol Gm (+) organism but not for Gm (+) organism but not for

Gm (-) bacteriaGm (-) bacteria Side effect:Side effect:

1.1. Vacuolar encephalopathyVacuolar encephalopathy

2.2. teratogenicteratogenic

3. Iodophores:3. Iodophores: 1% iodine – iodine is liberated 1% iodine – iodine is liberated

when the compound is diluted when the compound is diluted with waterwith water

For gm (+) and (-) but not for For gm (+) and (-) but not for sporesspores

3. Chlorhexidine Gluconate:3. Chlorhexidine Gluconate: For gm (+), (-) and fungiFor gm (+), (-) and fungi Sporicidal at elevated Sporicidal at elevated

temperaturetemperature This plus 4% isopropanolol This plus 4% isopropanolol

-----> surgical hand scrub and -----> surgical hand scrub and skin preparationskin preparation

endend

Health & Medicine

Surgical infections