SURGICAL INFECTIONS

1. Major & Minor Surgical Site infections

2. Abscess, Cellulitis, Lymphangitis, Boil & Carbuncle
3. Universal Precautions
4. Prevention of Surgical infections
5. Wound dressings
6. Skin grafts & flaps

Dr. J. Suresh, MBBS(GOLD MEDAL), MS(Osmania)GOLD
MEDAL, DNB(GOLD MEDAL), MRCS(UK), FICPS FELLOWSHIP IN TRAUMA AND BREAST
AND COLORECTAL SURGERY
 1. MAJOR & MINOR SURGICAL SITE

INFECTIONS
Surgical site infection is defined as –
 Wound infection in < 30 days of Surgery
 Wound infection in < 1 year of Implant cases
 Most common SSI pathogens are all gram-positive cocci –
Staphylococcus epidermidis, Staphylococcus aureus, Enterococcus
 For infra inguinal infections,
E.coli , Klebsiella are potential pathogens



CLASSIFICATION OF SSI


 According to Depth of Wound infections
 Superficial SSI – Cellulitis, Abscess, Bacteremia
 Deep SSI – Deep muscular layer infection,
 Organ space infection

 Superficial incisional SSI

 It occurs within 30 days of operation; involves only skin and subcutaneous tissue; and one of
following:
1. Purulent drainage (culture documentation not required) ,

2. organisms isolated from fluid/tissue of superficial incision,

3. at least 1 sign of inflammation

Deep incisional SSI

 It occurs within 30 days of operation or 1 year if an implant is present; involves deep soft tissues
of the incision; and at least one of the following-
1. purulent drainage from the deep incision site without organ/space involvement

2. fascial dehiscence

Organ Space Infection

 It occurs within 30 days or 1 year if an implant is present; involves anatomic structures not
opened or manipulated during surgery; and one of the following
1. pus from a drain placed into organ/space, organism isolated by culture

Common Bacteria which cause Surgical infections are
1. Streptococci – Beta hemolytic streptococci
( Streptococcus pyogenes )
1. Staphylococci – Most common is Staph. aureus
2. Clostridia – Clos. perfringes cause Gas gangrene
- Clos. difficile cause Pseudomembranous enterocollitis
4. Bacteroids – non spore strict anaerobes colonizing Large bowel






SURGICAL INFECTIONS
 Decisive period – Upto 4 hour interval before bacterial growth becomes established
enough to cause infection
 Major SSI is defined as A Wound either discharges significant quantities of pus
spontaneously or needs a secondary procedure
 Minor SSI may discharge pus or infected serous fluid not associated with systemic
signs






 2. ABSCESS, CELLULITIS, LYMPHANGITIS,
BOIL & CARBUNCLE
a) Abscess – presents with clinical features of acute inflammation
- abscess contain hyperosmolar material that draws in fluid
- treatment needs Incision & Drainage
b) Cellulitis & Lymphangitis
 spreading, non suppurative, poorly localised, invasive
infection of the subcutaneous tissues
 Most commonly caused by Streptococci pyogenes
 Blood cultures are often NEGATIVE
 Sequelae – Abscess, Bacteraemia, Pyaemia, Local gangrene





CLINICAL FEATURES


1. Red, shiny stretched warm skin, with pitting oedema
2. Surrounding lymph vessels may be involved resulting in red streaks due to
lymphangitis
3. No sharp demarcation between involved & uninvolved area


 Treatment – Elevation of Limb & Antibiotics

c) Boil ( Furuncle)
 It is an acute staphylococcal infection of Hair follicle with peri folliculitis
 Often boil opens on its own and subsides
 Furuncle in External Auditory Canal is very painful because of rich nerve supply
 Boil common over the Back, Neck, Thigh
 Boil occur in Eyelash – Stye
occur in Axilla – causes Hidradenitis suppurativa
 Boil subsides spontaneously often with support of suitable antibiotics
 Multiple boils are common in Diabetics



 Treatment: Antibiotics, rarely Drainage is needed
 Complications:
1. Cellulitis
2. Hydradenitis
3. Boil in Dangerous area of Face cause
Cavernous Sinus Thrombosis

d) Carbuncle
 Meaning = CHARCOAL
 Infective gangrene of skin and sub cutaneous
tissue
 Main culprit : Staphylococcus aureus
 Most common site : Nape of the Neck, Back
 Common in Diabetics, Males
 In Carbuncle, Cluster of Furuncles are
connected subcutaneously causing deeper
suppuration & scarring
 Investigations: Urine Sugar & Ketone bodies
 Treatment : Control of Diabetes, Antibiotics,
Incision & Drainage

 GAS GANGRENE
 Caused by clostridium perfringes
( gram-positive anaerobic spore forming bacilli )
 Gas and smell are characteristic features
 Immuno-compromised patients are most at risk
 Antibiotic prophylaxis is essential when performing amputations to remove dead tissue








 3. UNIVERSAL PRECAUTIONS
INVOLVEMENT OF SURGEONS WITH HIV / HEPATITIS PATIENTS
UNIVERSAL PRECAUTIONS
 4. PREVENTION OF SURGICAL
a)
INFECTIONS
Pre-operative preparation
 Alcoholic hand gels will act as substitute for
handwashing but do not destroy the spores of
clostridium difficle and will result in
Pseudomembranous enterocolitis in immune
compromised patients
 Preoperative shaving if done only to be done in
operating theatre just before surgery ( Never do
the Night before )
 Hair clipping is Best
 Cream depilation is Messy
b) Scrubbing & Skin preparation
 Dilute alcohol based like Chlorhexidine or
Povidine Iodine used for scrubbing
include the Nails
 Skin preparation with One time more
concentrated Alcohol based antiseptic
solution
 Avoidance of preoperative hypothermia
and use of supplemental oxygen during
recovery reduces the rate of SSI


PROPHYLACTIC ANTIBIOTICS


Given at the time of induction and
repeated after 4 hours, if surgery is
prolonged
 Single shot of IV Long acting
antibiotic is Ideal
 No need in Clean surgeries

5. WOUND DRESSINGS
Category Characteristics Function Examples

Non Adherent Fabrics Fine mesh gauze with Protection, Scarlet Red,
Non adherent properties Moist environment Vaseline Gauze,
Xeroform

Absorptives
a) Gauze Wide mesh gauze Removal of exudates Wide mesh gauze

b) Foams Hydrophobic polyurethane Protection Lyofoam, Vigifoam
sheets
Category Characteristics Functions Examples
Occlusives
i. Non-biologics
a) Films Clear polyurethane Protective barrier against Tegaderm, Bioclusive,
membranes bacteria Opsite

b) Hydrocolloids Hydrocolloid matrix (gelatin, Absorbs water from wound Hydrocol, Tegasorb
pectin) exudates

c) Alginates Cellulose like Calcium alginate converted Algiderm
polysaccharides to Soluble sodium salt after
( contain Calcium salts ) contact with wound exudate

Rehydrating agents for dry
d) Hydrogels Polyethylene oxide wounds FlexiGel, Vigilon

ii. Biologics
a) Homograft Derived from Genetically Cadaveric skin
unique humans
b) Xerograft Interspecies graft Pig skin
c) Amnion Human placenta
d) Skin substitutes Different compositions Integra, Alloderm,
Apligraf, Biobrane
6. SKIN GRAFTS & FLAPS
 Graft
Graft is one which is taken from one site and kept in another site
It has No own blood supply
 Flap
Flap is one which has its own blood supply

Steps in Skin Grafting
a) Plasma imbibition: Upto 48 hours
b) Inosculation: 4-5 Days
c) Revascularisation & Angiogenesis: After 5 Days


 Skin Grafts are of 2 types
a) Partial thickness ( Thiersch ) – upto Superficial layer of the Dermis
b) Full thickness ( Wolfe ) – upto Full Dermis

Partial Thickness ( Thiersch ) Full Thickness ( Wolfe )

Easy uptake & survival Uptake is difficult

Large grafts can be derived Only small grafts can be taken

Cosmetically unacceptable Cosmetically good

Donor site heals without Donor site heal with contraction

Contraction
Most common donor site – THIGH Most common donor site –
BEHIND EAR, Fingers, Eye lids,
Fascial parts
 Flaps - 2 Types
1. Free Flaps
2. Local flaps