Dr.

Imad Al
Al--fahd
F.I.B.M.S ( General Surgery )
Assistant Professor,
Baghdad Medical College .
Consultant Surgeon,
Baghdad Teaching Hospital
2018 year of
the
accreditation
 The infection of a wound can be defined as the
invasion of organisms through tissues following
a breakdown of local and systemic host defenses,
leading to cellulitis, lymphangitis, abscess and
bacteremia.
 The infection of most surgical wounds is
referred to as Superficial surgical site infection
(SSSI).
 The other categories include:
 Deep SSI (infection in the deeper musculofascial layers)
 Organ space infection (such as an abdominal
abscess after an anastomotic leak).
A major SSI is defined as a wound that
either discharges significant quantities
of pus spontaneously (C+S revealed
infecting bacteria) or needs a
secondary procedure to drain it.
Minor wound infections may
discharge pus or infected serous
fluid but should not be associated
with excessive discomfort ,
systemic signs or delay in return
home.
It presents with clinical features of acute inflammation:
 Calor (heat),
 Rubor (redness),
 Dolor (pain),
 Tumour (swelling).
 To these can be added (Loss of Function).
 Pyogenic organisms, predominantly Staphylococcus
aureus.
 Pus contains dead/dying white blood corpuscles that
release damaging cytokines, together with tissue debris
and microorganisms.
 If it is not drained or reabsorbed
completely, a Chronic Abscess may result.
If it is partly sterilized with antibiotics, an
Antibioma may form.
If they spread
spread, they usually track along
planes of least resistance and point towards
the skin (perianal
perianal abscess culminating into
recto--anal fistula).
recto fistula
Most abscesses relating to surgical wounds
take 7–10 days to form after surgery.
 Abscess cavities need Incision and
Drainage
Drainage.
 No need for antibiotic, if the cavity is left
open to drain freely.
 Some small breast abscesses can be
managed by simple needle aspiration of
the pus and antibiotic therapy.
 Certain organisms are associated with
chronicity, sinus and fistula formation.
chronicity
Common ones are:
Mycobacterium and
Actinomyces.
 An abscess in a deep cavity, such
as the pleura or peritoneum,
may be difficult to diagnose.
 ultrasonography, computed
tomography (CT), magnetic
resonance imaging (MRI) and
isotope scans are all useful and
may allow guided aspiration
without the need for surgical
intervention.
 Cellulitis is the non-suppurative invasive
infection of tissues.
 There is poor localization in addition to the
cardinal signs of inflammation.
 Spreading infection caused by organisms
such as: haemolytic streptococci &
Staphylococci.
 Tissue destruction,
destruction gangrene and ulceration
may follow, which are caused by release of
proteases.
 Systemic signs (toxaemia
toxaemia):
fever, sweating, and rigors (chills).
 Cellulitis and lymphangitis

 Lymphangitis is part of a similar

process and presents as painful red
streaks in affected lymphatics.
 Lymphangitis is often accompanied
by painful lymph node groups in
the related drainage area.
Staphylococcal cellulitis of the face and orbit following
severe infection of an epidermoid cyst of the scalp.
Streptococcal cellulitis of the leg following a minor puncture wound.
 Sepsis is a spectrum
 Septic focus (SSSI or DSSI)
 Bacteraemia
 Endotoxaemia
 SIRS (clinical start of Septicaemia)
 Sepsis=SIRS with infection
 Severe Sepsis=Sepsis with evidence of organ dysfunction
 Septic shock= sepsis-induced hypotension and/or
tissue hypoperfusion despite fluid resuscitation.
 End-organ dysfunction  MOF (DEATH)
 can follow procedures undertaken
through infected tissues.
 instrumentation in infected bile,
blood, or urine.
 bacterial colonization of indwelling
intravenous cannulae.
 (SIRS) is a systemic manifestation of
sepsis.
 Septic manifestations and multiple organ
dysfunction syndrome (MODS) in SIRS.
 In its most severe form, MODS may
progress into multiple system organ
failure (MSOF): Respiratory, cardiac,
intestinal, renal and liver failure ensue in
consecutive succession in combination
with circulatory failure and shock.
 Systemic inflammatory response
syndrome
(2 or more out of 4)

Finding Value

Temperature <36 °C or >38 °C

Heart rate > 90/min

> 20/min or
Respiratory rate
PaCO2 <32 mmHg

<4x109/L (< 4000/mm³),

WBC
>12x109/L (> 12,000/mm³),

In 2016 screening by systemic inflammatory response syndrome

(SIRS) was replaced with qSOFA
 qSOFA (2 of 3)
quick Sepsis Related Organ Failure Assessment

Assessment qSOFA score

Low blood pressure
1
(SBP ≤ 100 mmHg)
High respiratory rate
( RR ≥ 22 1
breaths/min)
Altered mentation
1
(GCS < 15)
Blood culture bottles:
bottles:
orange label for anaerobes,
green label for aerobes, and
yellow label for blood samples from children
Sepsis is a three
three--stage syndrome

SIRS or qSOFA
I. Sepsis is defined as SIRS in response to
an infectious process (confirmed or
presumed).
II. Severe sepsis is defined as sepsis with
sepsis-induced organ dysfunction.
III. Septic shock is severe sepsis plus
persistently low blood pressure despite
the administration of intravenous fluids.
End--organ dysfunction MOF
End
 In a nutshell
SIRS Criteria (≥ 2 meets SIRS definition)
 Temp >38°
>38°C or < 36°
36°C
 Heart Rate > 90
 Respiratory Rate > 20 or PaCO2 < 32 mm Hg
 WBC > 12,000/mm3, < 4,000/mm3,
Sepsis Criteria (SIRS + Source of Infection)
 Suspected or Present Source of Infection
Severe Sepsis Criteria (Organ Dysfunction, Hypotension, or Hypoperfusion)
 Lactic Acidosis, SBP <90 or SBP Drop ≥ 40 mm Hg of normal
Septic Shock Criteria
 Severe Sepsis with Hypotension,
despite adequate fluid resuscitation
Multiple Organ Dysfunction Syndrome Criteria
 Evidence of ≥ 2 Organs Failing
Common

Anaerobic

Infections
 Gas gangrene:
 This is caused by C. perfringens.
 Gram-positive, anaerobic, spore-bearing bacilli
are widely found in nature. in soil and faeces.
 relevant to military and traumatic surgery and
colorectal operations.
 Immunocompromised ,diabetic or have
malignant disease are at greater risk.
 associated with severe local wound pain and
crepitus. (gas in the tissues noted on plain
radiographs).
 Antibiotic prophylaxis should always be considered
in patients at risk.
 intravenous penicillin and aggressive Debridement
of affected tissues are required.
 Amputation stump is covered by flufly bandage to
prevent faecal contamination with clostridia
spores.
 Clostridium tetani
 This is another anaerobic, terminal spore-bearing,
Gram-positive bacterium that can cause tetanus
tetanus.
 lockjaw (trismus).
 facial muscles spasm (risus sardonicus).
 Back muscle spasms cause arching (opisthtonos).
 Sometimes the spasms affect muscles of breathing
(dyspnoea).
 Prophylaxis with tetanus toxoid is the best
preventative treatment.
 In infection minor debridement of the wound.
 antibiotic treatment with benzyl penicillin.
 mixed pattern of organisms is responsible.
 Abdominal wall infections are known as
Meleney’s synergistic hospital gangrene.
 Scrotal infection as Fournier’s gangrene
gangrene.
 Almost always immunocompromised.
 Severe wound pain, signs of spreading
inflammation with crepitus and smell.
 Broad spectrum antibiotics and circulatory
support with debridement and wide
excision.
A classic presentation of Fournier’s gangrene of the scrotum
with ‘shameful exposure of the testes’ following excision of the gangrenous
skin.
 Anaerobic
I. bacteria
Spore-forming
Spore- Gram--positive bacilli,
Gram bacilli e.g.
 Clostridium botulinum (botulism),
 Clostridium perfringes (gas gangrene),
 Clostridium tetani (tetanus), and
 Clostridium difficile (pseudomembranous enterocloitis).

II. Non-
Non-spore
spore--forming bacteria
bacteria, which include:
Bacilli (rods), which can be either
Gram--negative
Gram negative, e.g. Bacteroides and Fusobacteria, or
Gram--positive
Gram positive, e.g. Actinomyces and Lactobacilli.
Cocci,, which can be either
Cocci
Gram--positive
Gram positive, e.g. peptococci (anaerobic staphylococci)
and peptostreptococci (anaerobic streptococci), or
Gram--negative
Gram negative, e.g. Acidaminococci.
Death is a spectrum
 Apoptosis
 Necrosis
 Slough
 Sequestrum
 Gangrene
 Septic shock
 MOF
 DEATH
 If an infected wound is under
tension, or there is clear evidence of
suppuration, sutures or clips need to
be removed, with curettage if
necessary, to allow pus to drain
adequately.
Delayed healing relating to infection in a patient on highdose steroids.
 When taking pus from infected
wounds specimens should be
wounds,
sent fresh for microbiological
culture and sensitivity.
sensitivity
 If bacteraemia is suspected, but
results are negative, then repeat
specimens for blood culture may
need to be taken.
The value of antibiotic prophylaxis is
controversial in non
non--prosthetic clean
surgery, with most trials showing no
surgery
clear benefit.
 Streptococci:
All are sensitive to penicillin and erythromycin.
Cephalosporins are suitable alternative in allergic
patients.
 Staphylococci:
Flucloxacilline,, Vancomycin
Flucloxacilline Vancomycin,, Aminoglycosides.
 Clostridia:
C. difficile is the cause of pseudomembranous
colitis. Vancomycin and Metronidazole.
colitis Metronidazole
Mixed streptococcal infection of a skin graft with very poor
‘take’.
After 5–6 days of antibiotics, the infection shown ABOVE is
under control, and the skin grafts are clearly viable.
 normal inhabitants of the large
bowel. E. coli and Klebsiella spp
spp. are
lactose fermenting.
 Proteus is non-lactose fermenting.
 Bacteroides
Bacteroides:
Colonize the large bowel, vagina
and
oropharynx.
Delayed primary closure of fasciotomy wound.
Skin layers left open to granulate after laparotomy for
faecal peritonitis. The wound is clean and ready for secondary
closure
Penicillin:
 Gram-positive pathogens, including
most streptococci, the clostridia and
some of the staphylococci.
 All serious infections, e.g. gas gangrene
require high doses of intravenous benzyl
penicillin.
Flucloxacillin:
Flucloxacillin
 staphylococcal infections.
Ampicillin and amoxicillin
amoxicillin:
 Enterobacteriaceae: Enterococcus faecalis.
Mezlocillin and Azlocillin
Azlocillin:
 Severe mixed infections, particularly those
caused by Gram negative organisms in
immunocompromised patients.
Cephalosporins::
Cephalosporins
 Intra-abdominal skin and soft-tissue
infections.
 when there is a risk of splashing, particularly with power
tools, use of a full face mask ideally, or protective spectacles;
• use of fully waterproof, disposable gowns and drapes,
particularly during seroconversion;
• boots to be worn, not clogs, to avoid injury from dropped
sharps;
• double gloving needed (a larger size on the inside is more
comfortable);
• allow only essential personnel in theatre;
• avoid unnecessary movement in theatre;
• respect is required for sharps, with passage in a kidney dish;
• a slow meticulous operative technique is needed with
minimised bleeding.
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