SURGICAL INFECTION, SIRS and

SEPSIS
 Koch’s postulates
• It must be found in considerable numbers in
the septic focus
• It should be possible to culture it in a pure
form from that septic focus
• It should be able to produce similar lesions
when injected into another host
 History
• Ignac Semmelweis :
– sepsis could be reduced by the simple act of
hand-washing
• Louis Pasteur & Joseph Lister :
– using antiseptics to the reduction of colonising
organisms in compound fractures
• Alexander Fleming:
– Discovery of the antibiotic penicilin
 Physiology
Protective Mechanism to Prevent Infection:
• Mechanical: epithelial surfaces
• chemical: low gastric pH;
• humoral: antibodies, complement and opsonins;
• cellular: phagocytic cells, macrophages,
polymorphonuclear cells and killer lymphocytes

All these natural mechanisms may be compromised

by surgical intervention and treatment.
 Causes of reduced host resistance to
infection
• Metabolic: malnutrition (including obesity),
diabetes, uraemia, jaundice
• Disseminated disease: cancer and acquired
immunodeficiency syndrome (AIDS)
• Iatrogenic: radiotherapy, chemotherapy,
steroids
 Risk factors for increased risk of
wound infection
• Malnutrition (obesity, weight loss)
• Metabolic disease (diabetes, uraemia, jaundice)
• Immunosuppression (cancer, AIDS, steroids,
chemotherapy and radiotherapy)
• Colonisation and translocation in the gastrointestinal
tract
• Poor perfusion (systemic shock or local ischaemia)
• Foreign body material
• Poor surgical technique (dead space, haematoma)
 Factors that determine whether a
wound will become infected

• Host response
• Virulence and inoculum of infective agent
• Vascularity and health of tissue being
invaded (including local ischaemia as well as
systemic shock)
• Presence of dead or foreign tissue
• Presence of antibiotics during the ‘decisive
period’
The risk factors for developing
a wound infection
 Classification of sources of infection
• Primary:
acquired from a community or endogenous source
• Secondary or exogenous; health care-
associated infection (HAI):
acquired from
– the operating theatre,
– the ward,
– contamination at or after surgery
Surgical Site Infection
 Major wound infections
• Significant quantity of pus
• Delayed return home
• Patients are systemically ill
 Minor wound infections
• may discharge pus or infected serous fluid
• but should not be associated with excessive
discomfort, systemic signs or delay in return
home
Southampton Wound Grading System
 Types of localised infection
• Abscess
• Cellulitis and lymphangitis
• Gas gangrene
• Clostridium tetani
• Synergistic spreading gangrene (synonym:
subdermal gangrene, necrotising fasciitis)
 Abscesses
• Abscesses need drainage with curettage
• Modern imaging techniques may allow
guided aspiration
• Antibiotics are indicated if the abscess is not
localised (e.g. evidence of cellulitis)
• Healing by secondary intention is encouraged
 Abscesses
Technique of Incision and Drainage

Place a latex drain into the depth of the cavity. Fix the drain to the edge of
the wound with a suture and leave in place until the drainage is minimal.
Alternatively, pack the cavity open, place several layers of damp saline or
petroleum gauze in the cavity leaving one end outside the wound
 Cellulitis and lymphangitis
• Non-suppurative, poorly localised
• Commonly caused by streptococci, staphylococci or
clostridia
• SIRS is common
• Blood cultures are often negative
 Gas gangrene

• Caused by Clostridium perfringens

• Gas and smell are characteristic
• Immunocompromised patients are most at risk
• Antibiotic prophylaxis is essential when performing
amputations to remove dead tissue
 Clostridium tetani
• anaerobic, Gram-positive bacterium
• more common in traumatic civilian or military
wounds.
• The signs and symptoms of tetanus are mediated by
the release of the exotoxin tetanospasmin
• high mortality
• Prophylaxis with tetanus toxoid
 Synergistic spreading gangrene
synonym: subdermal gangrene, necrotising fasciitis

• A mixed pattern of organisms

• Abdominal wall: Meleney’s synergistic hospital
gangrene
• scrotal infection: Fournier’s gangrene
• Patients are immunocompromised, such as diabetes
mellitus
• Severe wound pain, signs of spreading inflammation
with crepitus and smell are all signs of the infection
spreading
• Untreated, it will lead to widespread gangrene and
MSOF.
 Treatment Of Surgical Infection
• When possible, tissue or pus for culture
should be taken before antibiotic cover is
started
• The choice of antibiotics is empirical until
sensitivities are available
• Wounds are best managed by delayed
primary or secondary closure
 Secondary closure of wound

The wound is open, and the edges are not approximated.

A potentially contaminated wound is best left open
lightly packed with damp saline soaked gauze and the
suture closed as delayed primary closure after 2–5 days
SYSTEMIC INFLAMMATORY RESPONSE AND MULTIPLE
ORGAN DYSFUNCTION SYNDROMES (MODS)
• Gut failure, colonisation and translocation related to the
development of multiple organ dysfunction syndrome
(MODS) and systemic inflammatory response syndrome
(SIRS)
Systemic Inflammatory Response
Syndrome (SIRS) and Sepsis
 
 Definitions of infected states
• SSI is an infected wound or deep organ space
• SIRS is the body’s systemic response to an
infected wound
• MODS is the effect that the infection
produces systemically
• MSOF is the end-stage of uncontrolled MODS
The Management of sepsis
THANK YOU