Surgical Infections Surgical Infections

RENATO R. MONTENEGRO, , MD, , FPSGS

History Definition & Classification Principles of Treatment Surgical S i l Infections I f i Surgical Site Infections Antibiotic Use in surgery Treatment Failure

History
Pre-anesthetic, pre-Listerian era 1842 Anesthesia (Morton and Long) 1865 The antiseptic antiseptic principle principle or Listerian method 1880 - 1890 Aseptic Surgery 1940 Antibiotic use

History
Pre-anesthetic, pre-Listerian era

surgical g history y= death from infection mortality rates for amputation in times of war (1745 and 1865) = 25 to 90 %

Ether Anesthesia, 1842

The Antiseptic Principle, 1865

Joseph Lister demonstrated that antisepsis could prevent infection 1867 publication: compound fractures healed without infection when the wounds were treated with carbolic acid. The Listerian Method emphasized antiseptic treatment of wounds after the operation

History

1880 1890 , Aseptic Surgery

Antibiotic Era
End of the 19th century - bacterial cause of surgical infection was appreciated Discovery of Penicillin (Alexander Fleming, 1928) Clinical use of Penicillin (Howard Florey, 1940)

William Stewart Halsted = rubber gloves, hand washing, masks, caps, gowns Ernst Bergman = chemical and steam sterilization of instruments Today, we wash our hands before an operation

Surgical Infections
defined as infections that require operative treatment

or result from operative treatment

(FIGURE 47-2) Mortality rates from appendicitis since 1880. The landmak paper by Fitz was published in 1886. Penicillin became widely available in the late 1940s.

Medical vs Surgical Infections

MEDICAL INFECTIONS COMMUNITY ACQUIRED INFECTIONS PATHOGENS host defenses are usually intact usually single and aerobic Typically, they possess virulence properties TREATMENT Antibiotics SURGICAL INFECTIONS result of damaged host defenses frequently mixed, aerobes and anaerobes; pathogens are opportunistic usually originate from the patient's own endogenous flora Surgical or other invasive procedure

TYPES OF SURGICAL INFECTIONS

Soft Tissue Infections
Cellulitis and Lymphangitis Necrotizing Soft Tissue Inf. Tetanus

Prosthetic Device Associated Infections

(cardiac valves, pacemakers, vascular grafts, and artificial joints) j )

Body Cavity Infections

Peritonitis and Intraabd. abscess Empyema Other Closed-Spaced Infections

Nosocomial Infections
urinary tract infections, wound infection, lower respiratory infection, vascular catheterrelated

Principles of Therapy
host defenses and antibiotic therapy are adequate to overcome most infections operative tx is generally required when host defenses cannot function properly or when there is continuing contamination with microorganisms non-operative treatments hasten recovery (chest physiotherapy, increase fluid intake, immobilization and elevation of extremity)

Why Surgery is required

Control of septic focus Drainage of infected fluid collections Debridement of infected necrotic tissue Removal of infected foreign bodies Correction of anatomic abnormalities

Operative treatment :
necrotizing soft tissue infections body cavity infections (peritonitis, pericarditis, pe ca d t s, empyema) e pye a) confined tissue, organ, and joint infection (abscess, septic arthritis) prosthetic deviceassociated infections

abscesses
phagocytic cells cannot function properly with the metabolic conditions in abscesses antibiotics penetrate abscesses poorly antibiotics work best on actively dividing bacteria necrotic tissue and foreign bodies inhibit the proper functioning of host defenses

abscesses
phagocytic cells cannot function properly with the metabolic conditions in abscesses antibiotics penetrate abscesses poorly antibiotics work best on actively dividing bacteria necrotic tissue and foreign bodies inhibit the proper functioning of host defenses

Infections resulting from operative tx

Surgical site infection surgical wound infection SSI postoperative abscess postoperative (tertiary) peritonitis and other body cavity infections prosthetic devicerelated infection hospital-acquired infections

Definition of Surgical Wound Infection

Superficial Surgical Wound Infection
Infection at incision site above the fascial layer within 30 days after operation plus any of the ffg: There is purulent drainage from the incision or a drain site. An organism is isolated from culture of fluid that has been aseptically obtained from a wound that was closed primarily. The wound is opened deliberately by the surgeon, unless the wound is culture-negative.

Definition of Surgical Wound Infection

Deep Surgical Wound Infection
Infection at operative site at or beneath fascial layer w/in 30 days after operation if no prosthesis was used and w/in 1yr if an implant was used plus any of the ffg: The wound spontaneously p y dehisces or is deliberately y opened by the surgeon when the patient has a fever (>38 C) and/or there is localized pain or tenderness, unless the wound is culture-negative. An abscess or other evidence of infection directly under the incision is seen on direct examination, during operation, or by histopathologic examination. The surgeon diagnoses infection.

Determinants of Infection
Microbial Pathogenicity Host Defenses
Local Host Defenses Systemic Host Defenses

The Wound Surgical Technique

Use of Antibiotics in Surgery

Prophylactic Antibiotics Therapeutic Use of Antibiotics

Surgical wound classification

Based on theoretical number of bacteria present in the wound Predicts the likelihood of developing wound i f ti infection Basis for use (or non-use) of antibiotics Basis for prophylactic vs therapeutic use of antibiotics

Empiric Therapy Definitive Therapy

Wound Classification
WOUND CLASS Clean Cleancontaminated Contaminated Dirty INFECTION RATES
1.5 to 3.9 % (<2%)

ANTIBIOTIC USE none

3.0 to 4.0 % 8.5 % 28 to 40 %

prophylactic therapeutic therapeutic

Decrease in wound infection rates in the 4 wound classes with the use of antibiotics

Treatment Failure in Surgical Infections

Treatment Failure in Medical Infections

1. The initial operative procedure was not adequate. 2. The initial procedure was adequate but p has occurred. a complication 3. A superinfection has developed at a new site. 4. The drug of choice is correct, but not enough is being given. 5. Another or a different drug is needed.

4. The drug of choice is correct, but not enough is being given. 5 Another or a different drug is needed 5. needed. 3. A superinfection has developed at a new site. 2. The initial procedure was adequate but a complication has occurred. 1. The initial operative procedure was not adequate.