wound infection

(surgical site infection)

Univesity of Al-Qadissiyah
College of Medicine
Dr. Ali J. AL-Shammari
wound infection

infections that require operative

treatment or result from operative
treatment.
factors inhibit the micro-organisms
from causing infection :-

• 1- mechanical barriers like skin,

nasal hair ,mucous secretion .
• 2- chemical factors : low gastric pH
• 3- humoral factors : antibodies,
complement and opsonins;
• 4- cellular factors : phagocytic cells,
macrophages, polymorphonuclear
cells
factors predisposing to wound infection are :-

• I- general factors :
• 1- immune-compromised state : as diabetes , tuberculosis , using
drugs as steroids or chemotherapy , radiotherapy , renal failure.
• 2- Malnutrition (obesity, weight loss, anaemia , ).
• 3-avoid use of prophylactic antibiotic in decisive period.
• 4- Virulence and inoculum of infective agent .
• 5- duration of the procedure.
• 6- hypothermia or hypoxia .
• II- local factors :
• 1- presence of foreign body .
• 2- presence of dead tissue .
• 3- poor surgical technique.
• 4- poor blood supply. (smoking , peripheral vascular disease ).
• 5- nature of operation as bacterial translocation in colonic surgery.
• 6- defect in sterilization technique.
• 7- open vs laparoscopic technique .
- Sources of infection :

• 1- Primary or acquired :
from an endogenous source (such as
that following a perforated peptic ulcer)
• 2- Secondary or exogenous :
acquired from the operating theatre
(such as inadequate air filtration) or the
ward (e.g. poor hand-washing
compliance) or from contamination at or
after surgery (such as an anastomotic
leak)
 Classification of Surgical wounds :
• According to bacterial load at the time of surgery
Important into:
• 1- Clean wounds (class I) include those in which
opened by sharp clean instrument ,no infection is
present ,only skin microflora potentially contaminate
the wound ,no hollow viscus that contains microbes
is entered, e.g. non complicated lipoma excision
,risk of surgical site infection about ( 1-2 %)

• 2- Clean/contaminated wounds (class II) include

those in which ,a hollow viscus such as the
respiratory, alimentary, or genitourinary tracts is
opened under controlled circumstances without
significant spillage of contents ,risk of surgical site
infection about ( < 10 %)
Classification of Surgical wounds ( types ):
• 3- Contaminated wounds (class III) include
• open accidental wounds encountered early
after injury, those with extensive introduction of
bacteria into a normally sterile area of the body
due to major breaks in sterile technique, gross
spillage of viscus contents such as from the
intestine ,risk of surgical site infection about (15
- 20 %).
• 4- Dirty wounds (class IV) include traumatic
wounds in which a significant delay in treatment
has occurred ,the presence of overt infection as
evidenced by the presence of purulent material
,those created to access a perforated viscus
accompanied by a high degree of contamination
, risk of surgical site infection about ( < 40 %)
Surgical Site Infections :

• Surgical site infections (SSIs)

are infections of the tissues,
organs, or spaces exposed by
surgeons during performance of
an invasive procedure.
Classification of Surgical Site
Infections ( types ) :
• I- Incisional which is sub-classified into
• a- superficial (limited to skin and
subcutaneous tissue)
• b- deep incisional categories (limited to
musculoskeletal layer )
• II- Organ space SSI .
Prevention of SSI :-
• I- Preoperative care :
• cleaning and antiseptic scrub using
chlorhexidine decreases bacterial
colonization by 80% .
• Surgical site to be shaved or clipped in
the operation theatre. within 2 hours of
beginning of the surgery
• Obvious infection in patient if exists
should be treated.
• Prolonged preoperative admission should
be avoided for an elective surgery as
increase risk of nosocomial infection .
Prevention of SSI
• II- Intra-Operation Theatre :
• One should ensure that sterile caps, masks, gowns
and sterile gloves are used.
• Proper skin cleaning is needed on table after
anaesthesia using antiseptics like povidone iodine.
• One should ensure that all drapes are dry
throughout the procedure and all instruments are
thoroughly sterilised.
• surgical skills care as gentle tissue handling,
absolute haemostasis, holding tissues using
instruments as much as possible, using appropriate
suture materials, avoiding dead space during
closure are certain essential on table tips to reduce
SSI.
• One should consider leaving wounds open if it is
severely contaminated.
Prevention of SSI :-
• III . Preventive ( prophylactic ) Antibiotic Therapy:
• It is used whenever high-risk of infection is
associated with the procedure( e.g clean
contaminated wound , immunocompamised
patient).
• Antibiotics should be administered as close to the
incision time as possible ,before induction of
anaesthesia.
• Selected antibiotic should have activity against
likely pathogens.
• Postoperative systemic antibiotics for 24 hours
(beyond 24 hours not shown to reduce SSI).
• Oral antibiotic bowel preparation with appropriate
mechanical bowel preparation.
Prevention of SSI

• IV- Enhancement of Host Defences :

• Increased oxygen delivery facilitates phagocytic
eradication of microbes.
• Optimizing core body temperature is important
as warmer patients resist bacteria better.
• Blood glucose control is essential even to
nondiabetics as well.
- Management of SSI :

• SSI is managed depending on the type of

SSI—superficial, deep or organ space.
• All infected material and pus should be
removed from the wound site (drainage and
debridement respectively ) .
• Sutures are removed to allow free drainage of
infected material.
• Infected fluid is sent for culture and sensitivity
and suitable antibiotics are started.
• Once wound shows signs of healing by healthy
granulation tissue, secondary suturing is done.
Or it is allowed to heal by scarring.
Abscess :-
• is collection of pus inside cavity .
• pus is composed of :-
-dead and dying white blood cells that release
damaging cytokines, oxygen free radicals and other
molecules.
• An abscess is surrounded by an acute
inflammatory response and a pyogenic
membrane composed of a fibrinous exudate and
oedema and the cells of acute inflammation.
Types of abscess :-

• 1- Pyogenic ( hot ) abscess.

• 2- Cold abscess .
• 3- Pyaemic abscess.
• 4- Metastatic abscess.
Mode of Infection in all types :-

• 1- Direct
• 2- Haematogenous
• 3- Lymphatics
• 4- Extension from adjacent tissues
Bacteria Causing Abscess :-

• 1- Staphylococcus aureus ( most

common ).
• 2- Streptococcus pyogenes.
• 3- Gram-negative bacteria (E. coli,
Pseudomonas, Klebsiella).
• 4- Anaerobes
Clinical Features :

• described by Celsus : ( calor (heat), rubor

(redness) , dolour (pain) , tumour(swelling),
Functionless (loss of function).
• 1- Fever often with chills and rigors.
• 2- Localised swelling which is smooth, soft and
fluctuant.
• 3- Visible (pointing) pus.
• 4- Throbbing pain and pointing tenderness.
• 5- Brawny induration around.
• 6- Redness and warmth with restricted
movement around a joint. (Commonly cellulitis
occurs first which eventually gets localized to
form an abscess.)
Investigations of abscess :
• 1- Total count is increased.
• 2- Urine sugar and blood sugar is done to rule
out diabetes.
• 3- USG of the part or abdomen or other region
is done when required.
• 4- Chest X-ray in case of lung abscess.
• 5- Gallium isotope scan is very useful.
• 6- CT scan or MRI is done in cases of brain
and thoracic abscess.
• 7- Investigations, relevant to specific types:
Liver function tests, PaO2 and PaCO2
estimation, blood culture.
Complications of an Abscess :

• 1. Bacteraemia, septicaemia, and pyaemia.

• 2. Multiple abscess formation.
• 3. Metastatic abscess.
• 4. Destruction of tissues.
• 5. Antibioma formation (common in breast
abscess). Once abscess forms, thick fibrous
tissue develops around abscess cavity because
of antibiotics. Cavity contains sterile pus as
thick flaques. It is nontender, localised, smooth,
hard swelling. Antibioma may be excised.
• 7- Sinus and fistula formation.
Treatment of abscess :-

• - Drainage (dependent aspiration ).

• - Antibiotic
• - Pus is sent for culture and sensitivity.
• - Biopsy should be done in suspected
tuberculosis or malignancy.
• - Treating the cause is important.
2- Cold abscess:

• is common in neck. It can also

occur in groin, intercostal space,
loin or any site where tuberculous
caseating material with cheesy
content can get collected and
localized.
• Cold abscess may originate from
tuberculosis of spine (thoracic or
cervical spines), lymph node,
internal organs, bone .
Clinical Features :-

• lacks most of clinical features of hot

abscess , therefore called cold
abscess.
• It is common in young but can occur
in any age group.
• Equal incidence in both sexes .
• which is smooth, no erythema ,
nontender, soft, fluctuant, non
transilluminating , with restricted
mobility but is not adherent to skin.
Investigation :

• - Cbc ( Raised ESR , low Hb (anaemia) ,lymphocytosis

• positive Mantoux test
• chest X-ray may show pulmonary tuberculosis,
aspiration of cold abscess
• (FNAC) to see microscopically epithelioid cells. Acid
fast bacilli may be identified from the aspirated fluid
using Ziehl-Neelsen stain.
• X-ray neck in case of cervical spine tuberculosis to
identify reduced joint space, vertebral destruction, soft
tissue shadow.
• MRI of cervical spine, US, CT scan neck are needed
to confirm the anatomical location, number of lesions.
Complication of Cold Abscess :

• Secondary infection of the cold abscess

making it tender.
• Formation of collar stud abscess (once
pressure increases inside the cold
abscess which will give way through the
deep fascia to reach the subcutaneous
plane to get adherent to skin).
• Sinus formation.
• Spread of disease to multiple lymph
nodes and other organs.
Treatment of cold abscess :-

• - Anti-tuberculous drugs.
• - Nondependent aspiration
of the cold abscess.
III – CELLULITIS :-

• It is spreading inflammation of
subcutaneous and fascial planes.
• Infection may follow a small
scratch or wound or incision or
insect/snake/scorpion bite.

• Types :
• - superficial .
• - deep .
Clinical Features :-

• 1. Fever, toxicity (tachycardia, hypotension).

• 2. Swelling is diffuse and spreading in nature.
• 3. Pain and tenderness, red, shiny area with
stretched warm skin.
• 4. Cellulitis will progress rapidly in diabetic and
immunosuppressed individuals.
• 5. Tender regional lymph nodes may be
palpable which signify severity of the infection.
• 6.No edge; no pus; no fluctuation; no limit.
Complication :-

1. Infection can get localised to form pyogenic abscess.

2. Infection can spread to cause bacteraemia, septicaemia,
pyaemia.
3. Can lead to local gangrene.
4. Extensive necrosis of skin and subcutaneous tissue e.g.
necrotizing fasciitis.
Treatment :-

• 1- Elevation of limb or part to reduce oedema so

as to increase the circulation
• 2- Antibiotics e.g. penicillins, cephalosporins.
• 3- Dressing
• 4- Bandaging.
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