SURGERY 1 B#6 L#1

Surgical Infection
Reynaldo Sinamban, MD, FPCS, FACS April 1, 2016

TOPIC OUTLINE o Layers of epithelium i.e. the skin barrier

I. Introduction B. Surgical Site Infections
II. Surgical Infections C. Types of Surgical Infections o Local environment features
A. Prophylaxis for wound infections III. Quiz  Skin lacks moisture
Hi guys! We opted not to include book trans since (a). the contents of the ppt are actually from the book
and (b) the remaining topics in the chapter of Schwartz regarding surgical infection is no longer covered  Flushing action of tears and urine
by the lecture. Don’t worry though because when we asked Doc Sinamban, although there are mixed  Cilia, peristalsis, mucus, pH
references for the lecture, he said that we could interchange the lecture and Schwartz as reference.
Thank you!  Local immunity IgA
o Systemic host defenses
LEGEND
 Decrease delivery of phagocytes
From the Lecture/PPT Slides  Diminution in blood flow
From the audio recording of the lecturer
From the Book/Other Sources – (Name of Book/Source)  Presence of devitalized or necrotic tissue, foreign bodies,
Transers/ STH hematomas and seroma
 Decrease vascular reactivity (uremic, old age, high dose of
I. INTRODUCTION steroid)
 Decrease production of phagocytes (chemotherapy)
o All of these things will compromise your host immune system

3. Surgical technique
o Handle tissues gently
o Remove devitalized tissues, blood
o Using drains
 As much as possible, avoid the use of drains unless
Figure 1. Triad of the pathophysiology of infection necessary because these are foreign bodies. They could also
Infection cause infection.
 In general, we have the basic three elements: first we should have  [Transers] A surgical drain is a tube placed near
the infectious agent; then we have the host, particularly a surgical incisions in the post-operative patient, to
diminished immune system; and of course a suitable environment. remove pus, blood or other fluid, preventing it from
o Interaction with these three elements leads to the development accumulating at the surgical site. The tube drains
of your surgical infection. externally.
 Microorganisms in host tissue or the bloodstream Figure 2: Surgical drain
 Inflammatory response to their presence o Avoid excessive cautery or burning, because it can cause
o Localized: Rubor, Calor, Dolor, Tumor, and Functio laesa (loss swelling and polynecrosis of the tissue
of function) o (-) tension in intestinal anastomosis
o Systemic: Systemic Inflammatory Response Syndrome (SIRS)  For example, in surgery wherein we join the bowel together,
we avoid tension to prevent leaks and to establish a good
From Block 4 L1: Criteria for SIRS: ≥ 2 of the following:
blood supply so that there is proper wound healing
 Temperature: <36 C or >38 C  Heart rate: >90 bpm o Good blood supply
 Respiration:  Leukocyte count:
>20/min or PaCO2 <32 mmHg <4,000/mm3 or >12,000/mm3 Classification of Surgical Wounds according to Risk of Infection
>10% immature (band) cells  1.5 – 5.4% infection rates
 Elective cases, primarily closed and undrained
Clean / Class I

 Factors that increase the number of serious surgical infection:  Nontraumatic, uninfected, no inflammation
1. Performance of more complicated and longer operations  No break in asepsis
o The longer the operation, the longer the magnitude of the  Respiratory, alimentary, genitourinary or oropharyngeal
surgery, the more you are prone to develop infection tracts not entered
2. Increase in the number of geriatric patients  Ex: Hernia repair, breast biopsy (clean
o Most of these patients have concomitant comorbidities incision[operations])
3. Use of implants and devices  2.1 – 9.5% infection rate
Contaminated/

4. Use of immunosuppressive agents  Alimentary, respiratory, genitourinary tract entered under

Class II
Clean-

5. Utilization of diagnostic and treatment modalities controlled conditions and without unusual contamination
o Some of these diagnostic modalities are considered  Minor break in technique
interventional  Mechanical drainage
6. Laxity of aseptic technique
 Ex: Appendectomy, biliary tract diseases
o If there is a breach in technique you can develop infection
7. Disregard for established surgical principles e.g. proper  3.4 – 13.2% infection rates
 Open, fresh traumatic wound
Contaminated /

scrubbing
8. Unwarranted reliance upon prophylactic antibiotic therapy  Gross spillage from gastrointestinal tract
Class III

o Sometimes we are so dependent on the use of antibiotics  Entrance of genitourinary or biliary tracts in presence of
that we forget we should maintain or practice the principle of infected urine and bile
aseptis or antisepsis  Major break in technique
 Ex: Penetrating abdominal trauma, large tissue injury,
Types of Infections enterotomy during bowel obstruction
 28 – 40% infection rates
infected / Class

Relative to Final Relative to Time of Onset

Outcome  Traumatic wound with retained devitalized tissue, foreign
Dirty and

• Pre-operative surgical infection bodies, fecal contamination or delayed treatment

IV

• Operative surgical infection  Ex: Perforated viscus encountered

• Self-limiting infection
• Serious infection
o Preventable operative surgical  Acute bacterial inflammation with pus encountered during
infection operation
• Fulminant infection (fatal
o Non-preventable operative
or permanently From Block 4 L4:
surgical infection
disabling) Table 1. Classification of wound based on microbial contamination
• Post-operative surgical infection
(UTI, respiratory, wound) Surgical Non-penetrating Trauma
Clean
Surgical
II. SURGICAL INFECTIONS (no particulate or
incisions into Bruises
Determinants of Infection microbial
skin, organs
1. Microbial Pathogenicity contamination)
o Virulence (tissue invading powers) Clean-contaminated
Surgical
o Infecting dose (105) (normal/natural env.
incisions in
Abrasions to top Cuts, tears,
o Ability to produce toxins (exotoxins/endotoxins) flora and particulate
nasal, oral,
skin layers only punctures
o Ability to resist phagocytosis and intracellular destruction matter present)
urinary,
2. Host Defenses bowel cavities
Any infected Any infected Any infected
Infected
Cala and Santiago Checked by: Bihag surgical non-penetrating trauma
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(by microbes)
wound wound wound
 Surgical Infection SURGERY I

A. Prophylaxis for Wound Infections  Low toxicity

nd
1. Avoidance of Bacterial Contamination  Administer a single full therapeutic dose. 2 dose given
postoperatively within 24 hours
 Environmental factors
 Utilization of a host defenses to augment antimicrobial effect
o Avoid exogenous and endogenous contamination
of the antibiotics
o Use of ultraviolet light and laminar flow ventilation
o Limitation of traffic in and out of the operating room
7. Reduction of colonic bacteria (intestinal antisepsis)
o Limitation of activity and talking within the operating room
 Pre-operative preparation of the patient  Reduce the high rates of infectious complication after colorectal
o Pre-operative shower with antimicrobial soap (chlorhexidine) surgery
o Cutaneous infection should be controlled or cleared before  Combined with mechanical cleansing of the colon
elective operation particularly on your excision site  Ideal drugs: bactericidal, minimally absorbed, no side effects
o Hair removal  Types:
 Promotes bacterial growth to 100% if the blade cuts the skin o 3-day bowel preparation
 Seropian & Reynolds study 406 clean wounds showed that  These patients are placed in liquid diet, antibiotics and
shaving increases infection rate to 5.6% from 0.6% where no mechanical cleansing of the intestine using enemas
shaving was done o Nichols-Condon Method:
 *Electric clippers with a single-use disposable head  2 days fluid diet (mechanical)
 We use these clippers right before surgery to prevent  Use of antibiotics that are minimally absorbed in the
wound infections gastrointestinal tract
o With regard to the skin preparation, the operative site is scrubed  Oral methronidazole and erythromycin 1 gm each and even
with a germicidal solution for around five minutes and painted neomycin given 4-6 gms
with povidine-iodine or chlorhexidine  1 gm give 1, 2, and 11 PM
o Use an antimicrobial incision drape o Whole GUT irrigation with polyethylene-glycol-electrolyte lavage
 We take this film on the area and then we cut. (GOLYTELY) 1 L  5 hours
o If you look at current literature, it says there that pre-operative
2. Operating room team and discipline oral antibiotic preparation is necessary because this will
 Wear clean scrub suits, cap and mask decrease infection rate with or without the use of mechanical
 Scrub hands and forearms with antimicrobial soap bowel cleansing
o Mechanical bowel cleansing can induce dehydration in a patient
 Careful washing of gowns and gloves
 Without intestinal asepsis = wound infection 48%
 Change punctured or damaged gloves
 With = wound infection 20%
3. Endogenous contamination
 Avoid bacterial contamination of the surgical wound at the time of B. Surgical Site Infections
transection of the GIT, GUT, and respiratory tract  SSIs are infections of the tissues, organs, or spaces exposed by
surgeons during performance of an invasive procedure
4. Importance of surgical technique  SSIs are classified into:
 Gentle care of tissues to minimize local damage o Incisional:
 All devitalized tissue and foreign bodies should be removed  Superficial – Within 30 days after the surgery you develop an
 Use monofilament sutures for potentially infected wound infection that is limited to skin and subcutaneous tissue.
o Use sutures that are less reactive to tissues  Deep incisional categories – Within 30-90 days you develop
 Avoid the presence of hematomas, seromas and dead spaces an infection, this time in the muscle and fascia
o Avoid the collection of fluid as this may serve as a nidus for o Organ/space infections
wound infection as well  Infections that occur 30-90 days after the surgery, this time
 Role of delayed primary closure (tertiary wound healing) involving the organs or the spaces in between organs
o Look at the possibility of doing a delayed primary closure,
especially if the wound is potentially infected, then you need not Risk Factors for Development of Surgical Site Infections
close the wound immediately  Patient Factors
o Older age o Anemia
5. Systemic Factors o Immunosuppression o Radiation
 Host resistance (control systemic diseases) o Obesity o Chronic skin disease
 Correct malnutrition o Diabetes mellitus o Carrier state (e.g.
o Studies have shown that when you operate on a malnourished o Chronic inflammatory process chronic Staphylococcus
patient, the chances of morbidity and mortality are higher o Malnutrition carriage)
o [Transers] Remember that state of nutrition is one of the factors o Peripheral vascular disease o Recent operation
assessed during pre-op assessment of a surgical patient  Local factors
 Avoid disturbance of circulation o Poor skin preparation
o Ischemia could produce infection o Contamination of instruments
 Avoid unnecessary use of drugs o Inadequate antibiotic prophylaxis
6. Systemic prophylaxis: chemotherapeutic and antibiotic o Prolonged procedure
o Local tissue necrosis
 Why avoid indiscriminate use of antibiotics?
o Hypoxia, hypothermia
o Secondary infection or superimposed infection
 Microbial factors
o Hypersensitivity reaction
o Prolonged hospitalization (leading to nosocomial organisms)
o May mask signs and symptoms of infection
o Toxin secretion
o Development of antibiotic resistant strains
o Resistance to clearance (e.g. capsule formation)
 Prophylactic antibiotics
o Given IV 30-60 mins before operation so that adequate blood
Surgical Management of the Wound
and tissue levels are present at the time that the skin incision is
made  In healthy individuals, class I and class II wounds may be
 It depends on the antibiotic. So if you are using other closed primarily, while skin closure of class III and class IV
antibiotics such as vancomycin, you have to wait for two- wounds is associated with high rates of incisional SSIs (25-50%)
hours for the tissue level of this antibiotic to be present. o If you close a dirty wound, you develop a surgical infection
o Another dose is given if operating time is > 4 hours and another  Class III and IV wounds should be packed open and allowed to
dose is given within 24 hours or when we do surgery in obese heal by secondary intention, although selective use of delayed
patients because the dose needed is higher primary closure has been associated with a reduction in
o Principles: incisional SSI rates
 Choose antibiotic effective against pathogens most likely to o It depends on the wound condition if you will close it or not
be encountered
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 Surgical Infection SURGERY I

infection,
Block 4 L4: meningitis,
Figure 3. H. influenza
o Primary intention – Inhibits bacterial DOC for:
closed by sutures (e.g. protein syn.; mycoplasma,
Erythromycin
lacerations) bactericidal in higher Legionnaire’s,
o Secondary Intention – dose actinomycosis
wound left open to heal Obligate
Metronidazole Bactericidal
itself by granulation anaerobic bacteria
tissue formation and Sulfonamides- (Oral; limited use for Community
contraction (no suturing) Trimethoprim nosocomial infection) acquired Gram (-)
o Tertiary intention – (One of the most
abused antibiotics in Nosocomial
placement of sutures 4-
the country because infections, nearly
 allow wound to stay Fluoroquinolones
you can buy it without all Gram (-)
open for a few days  prescription)
subsequent closure of Widest spectrum;
sutures highly effective vs.
most aerobic (S.
 Increased SSI rates associated with hyperglycemia Carbapenems aureus & P.
o It is recommended that clinicians maintain appropriate blood aeruginosa) as
sugar control in diabetic patients in the perioperative period to well as anaerobic
minimize the occurrence of SSIs bacteria
*DOC = Drug of choice, SE = Side effect
Antibiotics
 A chemical compound derived from or produced by living Diagnosis and Treatment of Surgical Infection
organisms capable at low concentration of inhibiting the life  Most important part of evaluation of patient suspected of having a
process of the micoorganisms surgical infection: careful history and PE
 Classification:  Laboratory and radiological technique
o Bacteriostatic – prevent the growth of bacteria but do not o Urinalysis, CBC, blood culture and sensitivity
destroy them. Affects early stages of protein synthesis in the o Ultrasonography/ CT scan/ MRI
ribosome o If the blood culture is positive then you can do culture-directed
o Bactericidal – agents that actively kill the bacteria; causes the antibiotics
ribosome to miscode and consequently induce the manufacture  As much as possible, when you manage these patients, give
of defective proteins and enzymes that poison the cell them [at first] broad spectrum antibiotics; [and] when your
cultures are in, you have to use culture-directed antibiotics to
Table 2: Antibiotic Mode of Action avoid resistance
Cellular site of  If with pus (color, odor and consistency)
Bactericidal Bacteriostatic
inhibition o Foul odor – Anaerobic
Penicillin o Greenish – P. aeruginosa
Cephalosphorin o Creamy – S. aureus
Cell wall synthesis
Vancomysin o Thin watery – Streptococcus/ Clostridium
Bacitracin
Polymyxin B Surgical intervention
Barrier function of cell
Colistin Nystatin  Primary principles of surgical treatment of surgical infection are:
membrane
Amphotericin B o Incision and drain of local abcess
Tetracyclin o Adequate debridement of necrotic tissue
Protein synthesis in the Streptomycin Chloramphenicol
o Removal of all hematomas, seroma and foreign bodies
ribosome Aminoglycoside Erythromycin o If with dead space  put sterile close suction tube
Clindamycin
DNA replication Griseofulvin C. Types of Surgical Infections
Soft Tissue Infections
Table 3. Antibiotic Agents  Cellulitis, erysipelas, lymphangitis
Drug MOA Activity vs.: o Erythema, local pain and tenderness, edema
Blocks the syn. of the o Fever, chills, malaise and toxic reaction
bacterial wall  o Pathogens: S. pyogenes, S. aureus, S. pneumoniae, H.
Penicillin Gram (+)
osmotic instability & influenzae, Aerobic and anerobic gram (-)
lysis o Treatment: Antibiotic, immobilization, elevation of the affected
Same as above; area and skin hygiene
Cephalosphorin arranged by Gram (+) & (-)
generation
(IV, intrathecally or
Amphotericin B Antifungal agent
instilled directly to site)
(Toxic SE: auditory
Gram (+) & (-),
Aminoglycoside branch damage,
mycobacteria
nephrotoxic)
Figure 4. Cellulitis, Erysipelas, Lymphangitis
Gram (+) & (-) not
sensitive to  Furunculosis, felon and carbuncle
Interfere with protein penicillin, TB o Soft tissue abcess
syn.; should be (probably early o Treatment: Incision and drainage; antibiotic; hygiene
Tetracyclines avoided in early stage since theTB
childhood (causes in our country is
yellowing of teeth) MDR),
actinomycosis,
nocardiosis
Broad spectrum;
Inhibits protein syn.,
DOC for typhoid
Chloramphenicol well absorbed orally Figure 4. Furunculosis, felon, carbuncle
fever & other
and parenterally
Salmonella
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 Necrotizing soft tissue infections
o Necrotizing fasciitis, strep gangrene, gas gangrene, bacterial
synergistic gangrene, clostridium myonecrosis and Fournier’s
gangrene
o Mixed aerobic and anaerobic gram (-) and (+) bacteria as well
as fungi, polymicrobial
o Patients at risk: elderly, immunosuppressed, diabetics, with
peripheral vascular disease; or those with a combination of
these factors
 Common among these host factors: compromise of the fascial
blood supply to some degree, coupled with the introduction of
exogenous microbes
o Most commonly affected: extremities, perineum, trunk & torso
o Manifestations
 Small break or sinus in the skin from which grayish, turbid
semipurulent material (“dishwasher pus”) can be expressed
 Skin changes (bronze hue or brawny induration), blebs or
crepitus
 Pain at the site of infection that appears to be out of
proportion to any of the physical manifestations
 Sepsis syndrome or septic shock
o Treatment:
 Debridement of all necrotic tissue (amputation)
 Reconstruction done once infection is controlled
 Antimicrobial agents vs. gram (+) and (-) aerobes and
anaerobes (e.g. vancomycin plus a carbapenem), as well as
high-dose aqueous penicillin G (16,000 to 20,000 U/d) for
clostridial pathogens
 Antibiotic therapy can be refined based on culture and
sensitivity results, particularly in the case of monomicrobial
soft tissue infections
Figure 5. Necrotizing soft tissue infections
Body Cavity Infections (Peritonitis and intra-abdominal abscess)
 Single organism, in children and adult
 Microbes invade the normally sterile confines of the peritoneal
cavity via hematogenous dissemination from a distant source
of infection or direct inoculation
 More common among patients with ascites and individuals
being treated for renal failure via peritoneal dialysis
o Those [with] in-dwelling catheter can have infection
Primary Peritonitis
 Diagnosis based on identification of risk factors:
o Physical examination: diffuse tenderness and guarding
without localized findings
o Absence of pneumoperitoneum on abdominal flat plate and
upright roentgenograms (i.e. X-ray picture)
o More than 100 WBCs/mL, and microbes with a single
morphology on Gram stain performed on fluid obtained via
paracentesis
 Treatment:
o Administration of an antibiotic to which the organism is
sensitive; often 14 to 21 days of therapy are required
o Removal of indwelling devices (e.g., peritoneal dialysis
catheter or peritoneovenous shunt) may be required for
effective therapy of recurrent infections
 Secondary to perforation or rupture of a hollow viscus
o Ruptured AP, perforated duodenal ulcer, complicated
diverticular disease, etc.
o What is important is infection control. When we cooperate
Secondary Peritonitis
with the patient to drain the abscess, we could drain the
abscess percutaneously
o Mortality rate is very high
 Diagnosis:
o computed tomographic (CT) scan – best
 Treatment:
o Combination of antibiotic agents or single agents with a
broad spectrum of activity can be used (anaerobic and
aerobic activity)
o Conversion of a parenteral to an oral regimen only when
the patient’s ileus resolves
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Surgical Infection SURGERY I
o Effective source control and antibiotic therapy is associated
with low failure rates and a mortality rate of approximately
5-6%; Inability to control the source of infection leads to a
(cpn’t) Secondary Peritonitis
mortality >40%
o Remove diseased organ
o Debridement of necrotic, infected tissue and debris
o Administration of antimicrobial agents directed against
aerobes and anaerobes
o Percutaneous drainage under imaging until: it is clear that
cavity collapse has occurred; output is <10-20 mL/d; no
evidence of an ongoing source of contamination is present;
and patient’s clinical condition has improved
o Surgical intervention required when: multiple abscesses;
abcesses in proximity to vital structures such that
percutaneous drainage would hazardous; and those in
whom an ongoing source of contamination (e.g. enteric
leak) is identified
 An intra-abdominal infection that persists or recurs 48 hours
following successful and adequate surgical source control
 Poorly understood
Tertiary Peritinnitis
 More common in immunosuppressed patients in whom
peritoneal host defenses do not effectively clear or sequester
the intial secondary microbial peritoneal infection
o For example: patients with HIV. When you do surgery in
these patients, you are confident that you removed the
source already [yet] the patient remains toxic even after the
surgery
 Associated with mortality rates >>50%
o Physical examination: diffuse tenderness and guarding
without localized findings
Prosthetic Device-Associated Infections
 Frequently eradicated after removal of the foreign body
Hospital-Acquired Infection or Nosocomial Infections
 Related to prolonged use of indwelling tubes and catheters for the
purpose of urinary drainage, ventilation, and venous and arterial
access
 Wound infection
 Most common source of fever post-op
 Urinary tract infection (most common)
o Treatment for 10-14 days with a single antibiotic
o Indwelling urinary catheters removed as quickly as possible
 Mechanical ventilator: Lower respiratory tract infection
o Associated with an increased incidence of pneumonia
o Diagnosis:
 X-ray evidence of one or more areas of pulmonary
consolidation
 Broncho-alveolar lavage to obtain samples  Gram stain and
culture to assess for the presence of microbes
o Surgical patients should be weaned from mechanical ventilation
as soon as feasible, based on oxygenation and inspiratory effort
 Vascular catheter-related infection: intravascular catheter
o Increase the risk of infection:
 Prolonged insertion
 Insertion under emergency conditions
 Manipulation under nonsterile conditions
 Use of multilumen catheters
III. QUIZ
1. True or False: A razor should be used to remove hair from the surgical site.
2. What is the initial preparation of the skin prior to surgery?
3. When administering antibiotics for surgical prophylaxis, which of the
following is not true?
A) Generally, the antibiotic should be administered within 60 minutes
before the incision
B) A patient should be redosed in the length of the operation exceeds
two half-lives of the selected agent
C) Drug infusion should be complete before inflation of a proximal
tourniquet
D) As long as the drug is given as a bolus, antibiotic infusions started
after the first incision are very effective
4. Which of the following wound classifications is correctly matched with its
description?
A) Clean: controlled opening with minor technique break
B) Clean-contaminated: procedures performed emergently
C) Contaminated: obvious infection present
D) Dirty: major spillage or technique break
E) None of the above
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 Surgical Infection SURGERY I

5. Which of the following methods is not considered to reduce the risk of

postoperative infection?
A) S. aureus decolonization
B) Supplemental warming
C) Intensive glucose control
D) 80% inspired oxygen
E) All of the above reduce the risk of postoperative infection
6. Which of the following would put a surgical patient at a greater risk for a
SSI?
A) Two-pack-per-day cigarette habit
B) Outpatient prescription of prednisone 10 mg every day
C) HIV-positive diagnosis
D) None of the above
E) All of the above
7. Which of the following organisms is most likely to cause an SSI in
orthopedic surgery?
A) Escherichia coli
B) S. aureus
C) Pseudomonas aeruginosa
D) Bacteroides fragilis
E) Candida albicans

End of Transcription

Answers
1. F. Electric clippers are used. Razors can produce nicks and cuts in the skin
making infection more likely.
2. Pre-op shower or cleaning with antimicrobial soap (chlorhexidine)
3. D
4. A
5. C
6. E
7. B

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