Surgical Infections

Dr Ali Emre Atıcı

Department of General Surgery
 Objectives

Definition
Pathogenesis of Infection
Predispositive Factors and Host Defence Mechanisms
Surgical Site Infections
Prevention and Treatment of Surgical Infections
Postoperative Nosocomial Infections
Sepsis
 Surgical Infections

Infections that require surgical treatment

or
related to operative interventions

Wound infections - Surgical site infections

Surgical nosocomial infections ?
(pneumonia, urinary tract infections, catheter infections)
 Pathogenesis

Microorganism Host Defenses

(virulance) (type&severity of immunosupression)

INFECTION

Environment
(Fluids, foreign bodies, etc.)
 Host Defenses Mechanism

Nonspecific Specific
Surface Mechanical barrier Immunoglobulins
(skin, mucosa) Secretory barrier
Ciliary motion
Movement
Cellular defense Phagocytic cells Cell-mediated immunity
(PNLs, eosinophils, mononuclear cells) (T lymphocytes & macrophages)
Natural killer cells
Humoral defense Lyzozyme Immunoglobulins
Complement
Interferon
 Causes of Impaired Host Resistance to Infection

Patient’s Underlying Condition Iatrogenic

Remote infection** Antineoplastic chemotherapy
Neoplasia Immunosuppressive therapy
Malnutrition (allograft recipients, autoimmune
Acute stress disorders)
(burns, trauma) Splenectomy
Metabolic illness
(DM**, uremia)
HIV
Aging
Obesity
Smoking**
 Microbiology of Intraabdominal Infections

Aerobes:
Escerichia coli, Klebsiella spp., Proteus spp., Enterobacter spp., Enterococcus spp.
Anaerobes:
Bacteriodes spp., Peptostreptococcus spp., Clostridium spp.,

Fungi:
Candida
 Surgical Site Infections

The term “surgical site infection” now replaces “surgical wound infection”

SSIs are infections of the tissues, organs or spaces expose by surgeons during
performance of an invasive procedure.

SSIs are classified into incisional and organ/space infections and the former are further
subclassified into superficial (limited to skin and subcutaneous tissue) and deep incisional
categories.
Surgical Site Infections
 Surgical Site Infections

Incisional Infection
Any incisional infection occuring within postoperative 30 days at any level above fascia described as;

Presence of any purulant discharge (culture may not reveal any opponent)
Any positive culture findings from primarily closed incision
Deliberate incision exploration
Infection diagnosis determined by the surgeon
 Surgical Site Infections

Organ / Space Infection

Any infection occuring within postoperative 30 days or within postoperative one year if any implant is
left described as;

Presence of any purulant discharge (through drains)

Any positive culture findings from intraabdominal samples
Spontaneous wound dehiscence
Presence of abscess
Infection diagnosis determined by the surgeon
 Risk factors for development of Surgical Site Infections

Remote infection
Elevated blood sugar (Diabetes)

Tissue perfusion and oxygenation

(smoking, hypothermia, hypoxia)
Obesity
Malnutrition
Steroid therapy
Nasal colonization with Staphylococcus aureus
 Surgical Site Infections

The development of SSIs is related to three factors:

The degree of microbial contamination of the wound during surgery

The duration of the procedure
Host factors
 Diagnosis of Surgical Site Infections

Redness
Swelling
Hyperthermia
Fluctuation
Purulent or turbid aspirate
 Surgical Site Infection

SOURCE

Source %
Flora of the patient 65
Flora of the health care providers 31
Environment 4
 Endogenous Gastrointestinal Microflora

Stomach
Duodenum Aerobes and anaerobes
Proximal small bowel <104/mL

Distal small bowel Enterobacteriaceae

Enterococcus spp 103-108/mL
Anaerobic organisms

Colon Anaerobic organisms

Bacteriodes fragilis 1012/mL
 Prevention and Treatment of Surgical Infections

“Whenever possible, identify and treat all remote infections to the surgical site before elective
operation, and postpone elective operations on patients with remote site infections until the infection
has resolved.
Category IA.”

Adequately control serum blood glucose levels in all diabetic patients and particularly avoid
hyperglycemia perioperatively.
Category IB.”
 Glucose Management

The stress response associated with surgery may induce hyperglycemia in nondiabetic patients
Catecholamines, IGF, glucocorticoids, and proinflammatory cytokines released in the perioperative period alter normal
glucose homeostasis by promoting catabolic processes and creating peripheral insulin resistance.

Hyperglycemia in the perioperative period is an independent risk factor for increased morbidity
and mortality
Diabetic patients have a higher incidence of
ICU admission
prolonged hospitalization
wound infections
 Prevention and Treatment of Surgical Infections

“Encourage tobacco cessation. At minimum, instruct patients to abstain for at least 30 days before
elective operation from smoking cigarettes, cigars, pipes, or any other form of tobacco consumption.
Category IB.”

No recommendation to taper or discontinue systemic steroid use (when medically permissible)

before elective operation.
Unresolved issue.”

“No recommendation to enhance nutritional support for surgical patients solely as a means to
prevent surgical site infection.
Unresolved issue.”
 Prevention and Treatment of Surgical Infections

Shorten preoperative hospitalization

Loose weight
Treatment of remote infections
Appropriate removal of hair
Shaving of hair before surgery increases risk of surgical site infections (small microabrasions serve as a portal for skin
flora to enter the bloodstream) It is recommended that hair not be removed, but if it is to be removed, to limit the area of
hair removal and remove with a clipper or depilatory by staff.
Shorten operative time
Restore host defenses
Decrease endogenous bacterial contamination
Wound surveillance
 Prevention and Treatment of Surgical Infections

Good Surgical Technique

Proper Asepsis and Antisepsis

Chemoprophylaxis

Aim: Prevention of infection rather than treating the infection

The use of antibiotics without any evidence of established infection or before contamination
occurs
 Chemoprophylaxis

Prophylactic antibiotic adminstration within 1 hour before incision

Appropriate antibiotic selection
Discontinuation of prophylactic antibiotic within 24 hours after surgery end time
Appropriate antibiotic selection
 Maintenance of Normothermia

Anesthesia induces a state of poikilothermia (hipothermia)

Hypothermia induces peripheral vasoconstriction, which decreases subcutaneous oxygen tension
(Hgb binds oxygen more avidly at lower temperature and prevents its release to the tissues)
Cutaneous tissues with reduced blood flow are likely to have decreased antibiotic delivery
Hypothermia decreases enzyme activities of leukocyte chemotaxis and coagulopathy
Hypothermia may also impair wound healing by impairment of collagen cross-linking
 National Research Council
Classification of Operative Wounds

Surgical wounds are classified based on the presumed magnitude of the bacterial load

Clean (class I)

Clean contamined (class II)

Contamined (class III)

Dirty and infected (class IV)

 Clean (class I)

Respiratory, alimentary, genitourinary tracts not entered

Nontraumatic

No inflammation encountered

No break in technique
 Clean contamined (class II)

Gastrointestinal or respiratory tracts entered without significant spillage

Genitourinary tract entered in absence of infected urine

Biliary tract entered in absence of infected bile

Minor break in technique

 Contamined (class III)

Entrance of genitourinary or biliary tracts in presence of infected urine or bile

Gross spillage from gastrointestinal tract

Major break in technique

Traumatic wound, fresh

 Dirty and infected (class IV)

Acute bacterial inflammation encountered, without pus

Transection of clean tissue for the purpose of surgical access to a collection of pus

Traumatic wound with retained devitalized tissue, foreign bodies, fecal contamination, and/
or delayed treatment, or from dirty source.
 Nosocomial infections

Occurs after the initial 48 hours of admission

Urinary tract infection
Catheter-related infection
Lower respiratory tract infection
Infection via transfusion
Bacteriemia
Thank you for your attention..