Surgical Infection

1. Historical 4. Prevention &

Background Treatment

Table of 2. Pathogenesis of 5. Infection of

Contents Infection Significance in
Surgical Patients

3. Microbiology of Infectious 6. Biological Warfare

Agents
HISTORICAL BACKGROUND
 Ignaz Semmelweis (1846)
• Handwashing

Historical Louis Pasteur (19th Century)

• Pasteurization
Background • “Germ Theory”

Joseph Lister (1867)

• Dressings saturated with
carbolic acid
 Robert Koch (1878-1880)
• Koch’s Postulates

Charles McBurney (1889)

Historical • “Source control”

Background Alexander Flemming

• Penicillin (Penicillium
notatum)

William Osler (1904)

• Cytokines
PATHOGENESIS OF
INFECTION
Host Defenses
• Barriers
o Physical
o Skin, respiratory, gut, and urogenital
o Secretory
o Host-barrier cells
o Resident Flora
o Colonization resistance

• Host-Response
o Macrophages, complement proteins, immunoglobulins, & polymorphonuclear
leukocytes (PMNs)
 “Infection is defined by the
presence of microorganisms in
host tissue or blood stream.”

Beilman GJ, Dunn DL. Surgical Infections. In: Brunicardi FC (editor). Schwartz’s Principles of Surgery.
11th ed. New York: McGraw-Hill; 2019: 160
Infection
• Several possible outcomes may occur
subsequent to microbial invasion and
interaction with host defense
a) Eradication
b) Containment
c) Locoregional Infection
d) Systemic Infection

• Systemic Inflammatory Response

Syndrome
• Sepsis
 MICROBIOLOGY OF
INFECTIOUS AGENTS
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 Bacteria
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• Majority of surgical infections
• Nosocomial infections
• Culture analysis
• Aerobes vs Non-aerobes
• Gram stain
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• Positive or Negative
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• Morphology
• Pattern of division
• Acid-Fast Bacilli

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 Fungi
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• Culture analysis
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• Special Stains
• Potassium Hydroxide (KOH)
• India Ink
• Methenamine Silver
• Giemsa Stain https://drfungus.org/wp-
content/uploads/2017/02/013MIKE.jpg

• Nosocomial infections

• Opportunistic infections in
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 Virus
• Difficult to culture

• Polymerase Chain Reaction (PCR)

• Mostly occur in
immunocompromised patients
PREVENTION & TREATMENT
OF SURGICAL INFECTIONS
 Prophylaxis
• Maneuvers to diminish the
presence of exogenous
and endogenous microbes

General Skin preparation

• Full body bath or shower

Principles •
•
Hair removal
Cleansed with alcohol-
based antiseptic agent

Antimicrobial therapy

Patient physiologic
management
 • Drainage of purulent material

• Debridement of all infected

Source Control
• Devitalized tissue and debris

Primary therapeutic modality to • Remediation of underlying

treat polymicrobial infections cause of infection
 • Agents are selected according to
activity against microbes likely to
be present at the surgical site

Appropriate Use
• Prophylaxis is limited to time
of Antimicrobial prior to and during the operative
procedure
Agents
• Prolonged procedures should be
given additional dose/s if drug
short half-life
 • Empiric Therapy

• Use of antimicrobial agents when risk

of surgical infection is high

• Often employed in critically ill patients

Appropriate Use
• Limited to 3-5 days
of Antimicrobial
• Duration of Administration
Agents
• Prophylaxis
• Single dose

• Monomicrobial Infections
• UTI – 3-5 days
• Pneumonia – 7-8 days
• Bacteremia – 7-14 days
 • Least toxic, least expensive agent
to which the organism is most
sensitive should be selected

Appropriate Use • Eradication Assurance

• Lack of elevated WBC count, lack of
of Antimicrobial band forms of PMNs on peripheral
smear, & lack of fever

Agents • Consider patient’s allergy

• Misuse of antimicrobial agents
may lead to multiagent drug
resistance among nosocomial
pathogens
INFECTIONS OF SIGNIFICANCE
IN SURGICAL PATIENTS
 • Surgical Site Infections (SSI)

• Intra-Abdominal Infections

Infections of • Organ-Specific Infections

Significance in • Postoperative Nosocomial
Surgical Patients Infections

• Sepsis

• Resistant Organisms

• Blood-Borne Pathogens
Surgical Site Infection
• Infections of the tissues, organs, or
spaces exposed by surgeons during
invasive procedures
• 2 Types:
o Incisional
o Organ/space Infection

• Development Factors:
o Degree of microbial contamination of the
wound during surgery
o Duration of procedure
o Host Factors
Wound Classification
• Class I (Clean) • Class III (Contaminated)
o No infection is present o Open accidental wounds encountered
o No hollow viscus that contains early after injury, with extensive
microbe is entered introduction of bacteria in a normally
sterile area of the body

• Class II (Clean/Contaminated)
o Include those in which hollow viscus
with indigenous microflora is opened
under controlled circumstances
without spillage of contents
Wound Classification
• Class IV (Dirty)
o Traumatic wounds in which a
significant delay in treatment has
occurred and in which necrotic tissue
is present, those created in the
presence of overt infection as
evidenced by the presence of purulent
material and those created to access a
perforated viscus accompanied by a
high degree of contamination
Intra-Abdominal
Infections
• Microbial contamination of peritoneal
cavity
• “Peritonitis”
• Primary
• Secondary

https://www.ncbi.nlm.nih.gov/books/NBK526129/bin/IMG_5128.jpg
Primary Peritonitis
• Microbes invade the normally sterile confines of peritoneal
cavity via:
o Hematogenous spread
o Direct inoculation

• Invariably monomicrobial
• Possible causative agents
o Escherichia coli
o Klebsiella pneumoniae
o Streptococcus pneumoniae

• Treatment
o Antibiotics for 14-31 days
o Removal of indwelling devices
Secondary Peritonitis
• Occurs due to subsequent contamination of the peritoneal
cavity due to perforation or severe inflammation and infection
of an intra-abdominal organ
• Source Control
o Resect or repair diseased organ
o Debridement of necrotic tissue
o Administration of antimicrobial agents directed against
aerobes and anaerobes
• Most morbid form:
o Colonic perforation due to large number of microbes
present
Secondary Peritonitis
• Patients in whom standard therapy fails:
o Intra-abdominal abscess
o Postoperative peritonitis
o Tertiary (Persistent) peritonitis

• Treatment
o Surgical Interventions
o Antibiotics for 3-7 days
o Most practitioners leave the drainage catheter in situ until
o Clear cavity collapse has occurred
o No evidence of ongoing contamination
o Output is <10-20 mL/d
o Patient’s clinical condition has improved
Organ-Specific Infections

Hepatic Abscess Secondary Pancreatic

Infections
Hepatic Abscess
• Rare

• 80% Pyogenic, 20% Parasitic &

Fungal forms

• Small (<1 cm), multiple

abscesses should be sampled
and treated with a 4-6 weeks
course of antibiotics

• Large abscess
o Percutaneous drainage with
parameters for antibiotic therapy
o Drain removal

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Secondary Pancreatic Infections
• Occur in approximately 10-15% of patients who develop severe
pancreatitis with necrosis
• Care for patients with severe acute pancreatitis:
o Staging with dynamic, contrast-enhanced helical CT

• Should be suspected in patients whose systemic inflammatory

response fails to resolve or in patients who initially recuperate only
to develop sepsis in 2-3 weeks
• CT-guided Aspiration of fluid from pancreatic bed
o Gram stain and culture analysis
o Gas within pancreas mandates surgical intervention
Secondary Pancreatic
Infections
• Open necrosectomy with
repeated debridement

• Attempt to delay surgical

intervention

• Video-Assisted Retroperitoneal
Drainage (VARD)
 These infections can be
classified according to whether
or not surgical intervention is
required

Infection of Drugs against Gram-

the Skin & positive skin microflora
are often selected
Soft Tissues
Best to delineate infections
based on soft tissue layer (s)
and pathogen(s) that caused
them
Infection of Skin & Soft Tissues
• Furuncles may drain spontaneously or require surgical incisions and
drainage
• Community acquired MRSA Infection should be suspected if
infection persists after treatment
• Patients at risk:
• Elderly, immunocompromised, or diabetics
• With peripheral vascular diseases
• Most common areas affected:
o Extremities, perineum, trunk and torso
Infection of Skin & Soft Tissues
• Grayish turbid semi-purulent material, skin changes, blebs or
crepitus
o Surgical intervention

• Antimicrobials:
o High-dose aqueous Penicillin G

• 50% of infections are polymicrobial and 50% monomicrobial

 Surgical Site Infections

Post-Operative Postoperative UTI

Nosocomial
Infections Nosocomial Pneumonia

Bacteremia
 • Considered based on
urinalysis
• WBCs, Bacteria, (+)
leukocyte esterase
Postoperative • Risk Factors
UTI • Prolonged duration of
catheterization, female sex

• Treatment
• 3-5 days single antibiotic
 • More likely infected with
drug-resistant pathogens

• Diagnosis:
Nosocomial • Purulent sputum, elevated
leukocyte count, fever, &
Pneumonia new chest X-ray
abnormalities

• Treatment
• Empirical therapy
 • May be associated with
indwelling intravascular
catherization

• Risk Factors
Bacteremia • Prolonged duration of
catheterization, insertion
during emergency or non-
sterile conditions, and use
of multilumen catheters

• Mostly asymptomatic
 • Catheter removal
• Purulence at exit site
• Severe sepsis syndrome

Bacteremia • Treatment
• Antibiotics 14-21 days
Sepsis
 Innate genetic
component or acquired
due to mutation

Resistant
Organisms MRSA most commonly
occurs as hospital-
associated infection in
chronically ill patients
 Extended spectrum β-
lactamase (ESBL)-
producing strains of
Enterobacteriaceae
Resistant vanA gene of

Organisms Enterococcus faecalis

and faecium

Emerging vancomycin-
resistance in S. aureus
Blood Borne-Pathogens
• Human Immunodeficiency Virus (HIV)
o Low risk of transmission from patient to surgeon
o Minimized by: (a) routine use of barriers, (b) immediate washing after contact
with blood or body fluids, and (c) careful handling and disposal of sharp
instruments
o Postexposure Prophylaxis
 3-drug regimen within 72 hours

• Hepatitis B Virus (HBV)

o Surgeons and healthcare personnel are at high risk
o HBV Vaccine

• Hepatitis C Virus (HCV)

o Low risk of transmission
o Treatment: Rivabirin, pegylated gamma interferon, sofosbuvir, boceprevir, &
telaprivir
 Bacillus anthracis (Anthrax)
Prophylaxis: Ciprofloxacin or
Doxycycline for 60 days

Yersinia pestis (Plague)

Biological Treatment: streptomycin,

doxycycline, fluroquinolone or
chloramphenicol
Warfare Variola (Small Pox)
Prophylaxis: Cidofovir

Francisella tularensis
(Tularemia)
Treatment: doxycycline &
criprofloxacin
 Thank You!

Reference:
Beilman GJ, Dunn DL. Surgical Infections. In: Brunicardi FC
(editor). Schwartz’s Principles of Surgery. 11th ed. New York:
McGraw-Hill; 2019: 157-179
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