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PATHOLOGY 1 POSTSURGICAL
INFECTIONS
BACKGROUND
• 19th century : attempts to reduce the surgical site infection (SSI) rate
Ø Hamilton – study of epidemiology and prevention of ”surgical fever”
Ø Lister – introduction of antiseptics (phenol) for surgical instruments and wounds
• Today’s problems :
Ø More surgeries and more complex (transplant , advanced oncologic surgery, etc.)
Ø Aged population and with a high incidence of obesity (and related diseases : diabetes, hypertension)
Ø Wide use of prosthetic devices in orthopaedic and cardiac surgery, hernia surgery (predispose to
microbial contamination and infection)
• 2-5% of all the surgical patients in the US, where SSI is the most common nosocomial
infection and S. aureus is the main pathogen
PATHOGENESIS
Microbial
characteristics
- Virulence
- Burden
Wound
Host
- Haemostasis
- Immune status
- Vitality
- Comorbidities
- Foreign bodies
• Source :
1) Endogenous contamination : Cutaneous flora next to the incision site (Gram-
positive cocci). Less frequent : inoculation from other sites by hematogenous
spread.
MICROBIAL
2) Exogenous contamination (occasionally) : Surgical personnel, operating
room environment, surgical instruments
CHARACTERISTICS • Burden :
- The higher, the greater the risk; with adequate antibiotic prophylaxis, > 100.000
microbes are required to cause SSI but the threshold diminishes in the presence of
prosthetic implants
• Virulence : surface components that facilitate adhesion, exo and endotoxins, biofilm
generation, surface capsule that prevents opsonization/phagocytosis
MICROBIOLOGY OF SSI
• E.g. : skin surgery, hernioplasty without mesh, thyroid • E.g. : colectomy, histerectomy, prostatectomy, lung
surgery, breast surgery resection
SURGICAL WOUNDS CLASSIFICATION
CONTAMINATED DIRTY
• Open, fresh, traumatic wounds (< 6 h of evolution) • Open traumatic wounds of > 6 h of evolution, with retention of
devitalized tissue/foreign bodies
• Major break in sterile technique
• Acute bacterial infection /perforated viscus
• Significant spillage of gastrointestinal contents
• Abscesses
• Opening of the biliary/genitourinary tract in the presence
of infection • Requires antibiotic treatment NOT prophylaxis
• Postoperative intraabdominal
abscess
• Transgastric endoscopic drainage
DIAGNOSIS OF SSI
v Superficial SSI :
• Wound opening, irrigation, local wound care
• Antibiotics in case of extensive wound erythema and/or signs of systemic infection
v Deep SSI :
• Surgical exploration, debridement, antibiotics
v Organ/space SSI
• Surgical exploration, debridement, drainage
• In selected cases (accessible intracavitary abscesses) : placement of radiologically-guided
percutaneous drains
• Antibiotics
Debridement : removal of the contents from a contaminated/infected space (exudate, foreign bodies, devitalized tissue)
FOOD FOR THOUGHT
Probiotics (according to WHO) : live microorganisms which confer beneficial effects to the host
when given in sufficient quantities.
Prebiotics are food ingredients, which escape digestion in the upper gastrointestinal tract to stimulate
the growth or activity of selective bacterial genera in the colon.
Synbiotics = combination of pre and probiotics in a single product
WHAT ABOUT TOOTH EXTRACTIONS ?