SURGICAL INFECTIONS

Dave Endel R. Gelito III, MD,

FPCS, FPSGS, MM
August 14, 2013
7 Up
HISTORICAL BACKGROUND
1. Infection related to surgical wound was the rule
rather than the exception.
Surgical infection is common among high risk
individuals. Low velocity bullets (speed of < 700
ft/s) are less fatal but have high infection rate
especially if surgery (e.g. amputation) is not
done correctly
2. Anesthesia
surgeons became more adept with
treatment
3. Persons that pioneered in management of
surgical infections:
o Louis Pasteur: Germ Theory
All infections are caused by the
presence and actions of a specific
microorganism.

d. the organism should be reisolated from

the newly diseased animal and shown
to be the same as the original
o Alexander Fleming
Discovered the first effective antibacterial
agent
As a result, cases of infections were
reduced
Came from penicillium (a fungus) which
produced substances with inhibitory
actions to S. Aureus
o Ignaz Semmelweis
hypothesized puerperal fever was caused
by putrid material by passage of this
material on examining fingers of medical
students and physicians
Formulated the use of chlorine water in
rinsing the hands
Reduced mortality rate from puerperal
fever to 1.5%
o Joseph Lister
Experimented on the use of carbolic acid
First intra-abdominal operation to treat infection
via source control was Appendectomy
performed by Charles McBurney

Robert Koch: Kochs Postulate

Developed postulates to identify the
association of organisms with specific
diseases:
a. the suspected pathogenic organism
should be present in all cases of the
disease and absent from healthy
animals
b. the suspected pathogen should be
isolated from a diseased host and
grown in a pure culture in vitro
c. cells from a pure culture of the
suspected organism should cause
disease in a healthy animal

PATHOGENESIS OF INFECTION
Host Defenses
o Prevent microbial invasion
o Limit microbial proliferation within the host
o Contain or eradicate invading organisms
o Include site specific defenses (first line of host
defenses)
Skin
Respiratory Tract
Ex. Entry of foreign body ---- action
of macrophages--- movement of
prganisms towards the upper
respiratory tract with the help of
cilia --- coughing out and release
o Circulate throughout the body
Polymorphonuclear neutrophils/PMNs
Causes eradication of microbes that
invade the systemic circulation
1

 Definitions
o Possible Outcome
Eradication
Containment
Ex. Acne
Locoregional infection with or without
distant spread of infection
Ex. Local infection that led to
myofascitis (inflammation of a
muscle and its fascia)
Systemic infection
o Infection identification of microorganisms in
host tissue or blood stream, plus an
inflammatory response to their presence
o SIRS/Systemic Inflammatory Response
Syndrome constellation of signs and
symptoms brought about by the presence of
inflammation; not localized
o Sepsis - presence of SIRS caused by infection (mediated by cascade of proinflammatory
mediators produced in a response to exposure
to microbial products
o Severe Sepsis - characterized by sepsis with the
presence of an organ failure
o Septic Shock - state of acute circulatory failure
identified by the presence of arterial
hypotension despite adequate fluid
resuscitation, without other identifiable cause.
- Most severe manifestation of infection

Relationship between infection & SIRS

Sepsis is the presence both of infection and the systemic

inflammatory response. Other conditions may cause SIRS as

well (trauma, aspiration, etc.). Severe sepsis is a subset of

sepsis.

Example of progession of infection:

Acute appendicitis --- peforation ---- peritonitis---SIRS--- sepsis--- severe sepsis ---- septic shock
MICROBIOLOGY OF INFECTIOUS AGENTS OF SURGICAL
SIGNIFICANCE
1. Bacteria
Identified using grams stain
Further classify according to
morphology
Pattern of division (clusters =
staphylococci, chains = streptococci)
Most common among surgical patients
a. Gram-positive bacteria
aerobic skin commensals (S. aureus
and epidermidis, Streptococcus
pyogenes) most common cause of
SSIs
enteric organisms such as E. faecalis
and faecium can cause
nosocomial infections (urinary tract
infections and bacteremia) in
immunocompromised or chronically
ill patients
b. Pathogenic Gram-negative bacterial
species
Family of Enterobacteriacae
Pseudomonas aeruginosa and
fluorescens and Xanthomas spp.
c. Anaerobic organisms
do not possess the enzyme
catalase, which allows for
metabolism of reactive oxygen
species
predominant indigenous flora In
many areas of the body especially
in the nasopharynx and
colorectum
ex: Propionibacterium acnes
d. Mycobacterium tuberculosis
once one of the most common
cause of death in Europe, causing
2

1 per 4 deaths in the 17th and 18th

centuries
2. Fungi
cause nosocomial infections
Candida albicans and related species polymicrobial infections or fungemia
Aspergillus species, Blastomyces
dermatitidis, Coccidioides immitis, and
Cryptococcus neoformans opportunistic pathogens that cause
infection in the immunocompromised
host
identified by use of special stains (KOH,
India ink, methanamine silver or
Giemsas stain
3. Virus

difficult to culture due to size and

necessity for growth
requires a longer time than is typically
optimal for clinical decision making
Polymerase Chain Reaction - allowed
for the of viral DNA or RNA
occur in the immunocompromised host
(e.g. prevent rejection of a solid organ
allograft)
Adenoviruses, Cytomegalovirus,
Epstein-Barr virus, Herpes simplex virus,
and Varicella-zoster virus

PREVENTION AND TREATMENT OF SURGICAL

INFECTIONS
1. Prophylaxis
Goal is to diminish number of exogenous
(surgeon) and endogenous (patient)bacteria
and not to eradicate
Host resident microflora of the skin (resident
and surgeon) and other barrier surface
represent a potential source of microbes
that can invade the body during trauma,
thermal injury or emergent surgical
intervention
a. Mechanical
Scrubbing
Hair Removal
Bowel prep

Sterile barriers (Sterile surfaces

should come in contact with
sterile surfaces; clean to clean
and dirty to dirty)
Gowning
Gloving
Drapes (placed after skin
preparation to isolate
operative site)
b. Chemical
Use of antiseptic on surface
(Povidone Iodine)
Antimicrobials are commonly used
(Neomycin, Erythromycin) for
prophylaxis
Erythromycin is not absorbed readily
and thus acts locally (ex. Colon)
Used to decrease number of
microorganism in the colon
Patient who also undergo surgery in
which consequences of infection
would be dire should receive
antibiotics (e.g. prosthetic graft
infection)
2. Source Controls
the primary precept of surgical
infectious disease consists of drainage
of all purulent material, debridement
of all infected devitalized tissue,
removal of foreign objects, and
remediation of the cause of infection.
Ex. Source: Appendicitis; Source
control: appendectomy
a. Drainage
b. Debridement
Ex. Diabetic Foot
c. Removal of foreign body
perform if removal of the
object will not harm patient
a potential source of infection
d. Remediation of underlying
cause
Ex. DM, immunosuppresion
3. Appropriate use of antimicrobial agents
a. Prophylaxis
No ongoing infection
Deals with clean wound
3

Given because of the high

probability of infection due to
presence of normal flora (E. Coli in
the colon & S. Aureus in the Skin))
selected according to their activity
to microbes likely to be present at
the surgical site
usually only single dose of
antibiotic given, but may require
additional doses for complex and
long surgical operations

b. Empiric
Comprises
the
use
of
antimicrobial agent when risk of
infection is high, based on the
underlying disease process
Should be Limited to a short
course (3 to 5 days)
Ex. In appendicitis, antimicrobials
are given because of the expected
presence of gram negative
microorganisms in the colon
c. Treatment of established infection/
Specific
Antimicrobials are given after
determination by gram stain or
culture and sensitivity
d. Duration
decided upon when regimen is
prescribe
Therapy for monomicrobial
infections:
3 to 5 days = UTIs
7 to 10 days = pneumonia
6 to 12 weeks = osteomyelitis,
endocarditis or prosthetic
infections
least toxic, least expensive and
most sensitive to which the
organism is sensitive to must be
the drug of choice.
e. Allergies
must be considered before
prescribing antibiotics
Patients undergo intradermal
testing ( ex: vancomycin)

f.

Misuse
rampant in the inpatient and
outpatient setting
emergence of Clostridium difficile
colitis, and other multidrug
resistant pathogens
must limit prophylaxis to the
therapy and not included in the
empiric therapy except under well
defined conditions

Issues on use of Antimicrobial agents:

1. Choice of antibiotics
Least toxic
Least expensive
Organism is most sensitive
2. Duration of treatment
Standard treatment?
INFECTIONS OF SIGNIFICANCE IN SURGICAL PATIENTS
Surgical Site Infections/SSIs
SSIs are infections of the tissues, organs, or
spaces exposed by surgeons during
performance of an invasive procedure.
Characterized as:
a. Incisional infection
i.
Superficial involvement above
fascia
It is limited to skin and
subcutaneous tissue.

ii.

Deep with fascial involvement

Effective therapy for incisional SSIs consists

solely of incision and drainage without the

addition of antibiotics. Antibiotic therapy is

reserved for patients with evidence of
cellulitiis and SIRS. The open wound often is
allowed to heal by secondary intention.

b. Organ/Space specific infection

Ex. Acute appendicitis,
dehiscence
ORGAN-SPECIFIC INFECTIONS
Hepatic abscesses:
Rare
80% pyogenic, 20 parasitic & fungal
Aerobes involved: E. coli, K.
pneumonia
Anaerobes involved: Bacteroides
spp., anaerobic streptococci, and
Fusobacterium spp.
Fungi involed: C. albicans and other
similar yeasts
Abscesses <1cm in size: sampled
and treated with antibiotics
Larger abscesses: percutaneous
drainage
Splenic abscesses- rare and treated in the
same fashion.
Recurrent hepatic and splenic abscesses
may require operative intervention.
Secondary pancreatic infections (i.e.
infected pancreatic necrosis or pancreatic
abscess) occur in 10 to 15% of patients who
develop severe pancreatitis with necrosis.
o Surgical treatment pioneered by
Bradley and Allen.
o Presence of infection should be
suspected in patients whose
systemic inflammatory response fail
to resolve, or those who initially
recuperate but develop sepsis
syndrome 2 to 3 weeks later.
o CT-guided aspiration of fluid from
the pancreatic bed for Grams stain
and culture analysis is of critical
importance.
o If Grams stain or culture is positive,
or there is identification of gas
within the pancreas on CT scan,
operative intervention must be
mandated.

Approximately 20 to 25% will develop GI

fistula, which either heals or can be
repaired after resolution of the pancreatic
infection.

The development of SSIs is related to three factors:

1. The degree of microbial contamination of the
wound during surgery
2. The duration of the procedure
3. Host factors (diabetes, malnutrition, immune
suppression, etc.)
SURGICAL WOUNDS

They are classified based on the

presumed magnitude of the bacterial load
at the time of surgery.
Classes:
1. Class I or Clean Wounds
Only skin microflora potentially
contaminate the wound
No hollow viscous that contains
microbes that entered
No infection is present
Ex. Hernia repair, mastectomy

Infection Rate (IR): 1 to 5.4%

2. Class II or Clean/Contaminated Wounds
A hollow viscous with indigenous
bacterial flora is opened under
controlled circumstances without
significant spillage of contents.
Includes the respiratory, alimentary,
or genitourinary tracts.
Ex. Cholecystectomy, elective GI
surgeries, colorectal surgery

IR: 2.1 to 9.5% For colorectal

surgery: 9.4 to 25%
3. Class III or Contaminated Wounds
Open accidental wounds
encountered early after surgery
Due to major breaks in sterile
technique
Incision through inflamed, nonpurulent tissue (open cardiac
massage)
Those with extensive introduction of
bacteria into a normally sterile area
of the body.
5

 Ex. Penetrating abdominal injury,

enterotomy, large tissue injury
IR: 3.4 to 13.2%
4. Class IV or Dirty Wounds
Traumatic wounds with significant
delay in treatments
Presence of necrotic tissue
Presence of purulent material
Those created to access a perforated
viscous
Ex. Severe peritonitis, perforated
dIverticulitis, necrotizing soft tissue
infections.
IR: 3.1 to 12.8%
There should be appropriate control of blood
sugar level in diabetic patients to minimize the
occurrence of SSIs. Adverse effects of
hyperglycemia on WBC functions have been well
documented.
National Research Council Classification of Operative
Wounds (taken from ACS Surgery: Principles and Practice 6th Ed)
Clean (class I) Non traumatic
No inflammation encountered
No break in technique
Respiratory, alimentary, or genitourinary
tract not entered
CleanGastrointestinal or respiratory tract entered
contaminated without significant spillage
(class II)
Appendectomy
Oropharynx entered
Vagina entered
Genitourinary tract entered in absence of
infected urine
Biliary tract entered in absence of infected
bile
Minor break in technique
Contaminated Major break in technique
(class III)
Gross spillage from gastrointestinal tract
Traumatic wound, fresh
Entrance of genitourinary or biliary tracts in
presence of infected urine or bile
Dirty and
Acute bacterial inflammation encountered,
infected (class without pus
IV)
Transection of tissue for the purpose of
surgical access to a collection of pus
Traumatic wound with retained devitalized
tissue, foreign bodies, fecal contamination,
delayed treatment, or all of these; or from
dirty source

INTRA-ABDOMINAL INFECTIONS
aka peritonitis
Microbial contamination of the peritoneal
cavity
(taken from Schwartz 9th ed pp. 124-125)

1. Primary Microbial Peritonitis

When microbes invade normally sterile
confines of the peritoneal cavity via
hematogenous dissemination from a distant
source of infection or direct inoculation.
Common among patients with ascites and
those being treated for renal failure via
peritoneal dialysis.
Monomicrobial
Rarely require surgical intervention.
PE reveals diffuse tenderness and guarding
without localized finding and absence of
pneumoperitoneum on abdominal flat plate
and upright roentgenograms
Presence of 100 WBCs/ml, and microbes
with a single morphology on Grams stain
(sample obtained through paracentesis)
Treatment: antibiotic for 14 to 21 days
Removal of indwelling devices (peritoneal
dialysis catheter or peritoneovenous shunt)
for recurrent infections
Can include E. Coli, K. Pneumoniae,
pneumococci and others
2. Secondary Microbial Peritonitis:
due to perforation or severe inflammation
and infection of an intra-abdominal organ
Ex.: appendicitis, GI tract perforation,
diverticulitis
Therapy:
o Source control to resect or repair
diseased organ
o Debridement of necrotic, infected
tissue and debris
o Administration of antimicrobial
agents against aerobes and
anaerobes
Low failure rates with effective source
control and antibiotic therapy, with
mortality rates of 5 to 6%
Inability to control risk of infection leads to
mortality greater than 40%

 70 to 90% response rate to effective source

control and antibiotic therapy; can lead to
tertiary microbial peritonitis
3. Tertiary/Persistent Microbial Peritonitis
In patients whom standard therapy for
secondary microbial peritonitis fails; they
develop intra-abdominal abscess and
leakage from a GI anastomosis leading to
post-operative peritonitis.
In immunosuppressed patients in whom
peritoneal host defenses do not effectively
clear or sequester the initial secondary
microbial peritoneal infection.
Microbes include: E. faecalis and faecium, S.
epidermidis, C. albicans, P aeruginosa
Even with effective antimicrobial agent
therapy, this disease process is associated
with mortality rates in excess of 50%
INFECTIONS OF THE SKIN & SOFT TISSUE
Classified according to whether surgical
intervention is required:
1. Antibiotics
Drugs that possess activity against the
gram-positive skin microflora
For superficial skin and skin structure
infections such as (cellulitis, erysipelas, and
lymphangitis)
2. Spontaneous drain or require surgical incision
and drainage
Furuncles or boils
3. Aggressive and immediate drainage and
altered antimicrobial therapy
Includes:
Meleney's synergistic gangrene
Rapidly spreading cellulitis
Gas gangrene
Necrotizing fasciitis
Antibiotics are prescribedif significant
cellulitis is present or if cellulitis does not
rapidly resolve after surgical drainage
Commonly acquired MRSA should be
suspected if infection persists after
treatment with adequate drainage and
antibiotics.
At risk patients: elderly,
immunosuppressed, or diabetic, peripheral
vascular disease (caused commonly by

compromise of the fascial blood supply &

introduction of exogenous microbes)
Initially, diagnosis is established solely upon
clinical findings
Prone to develop sepsis syndrome or septic
shock
Most commonly affected: perineum,
extremities, and torso (PET)
Examine entry site:
grayish, turbid semipurulent material
(dishwater pus)
presence of skin changes (bronze hue or
brawny induration)
blebs
crepitus
Pain at the site of infection that appears to
be out of proportion mandates immediate
surgical intervention
Radiologic studies should be undertaken
only in patients in whom the diagnosis is
not seriously considered
Antimicrobial agents directed against grampositive and gram negative aerobes and
anaerobes (Vancomycin, Carbapenem,
High-dose aqueous penicillin G)
50% of such infections are polymicrobial
Follow-ups and additional resection
ofinfected tissue and debridement
Adjunctive treatments:
a. Hyperbaric oxygen: infection caused by
gas forming organisms ( C. perfringens)
b. IV Ig - group A streptococcal infection
with toxic shock syndrome, patients
with a high risk of death, elderly,
hypotension or bacteremia
Necrotizing soft tissue infection

severe late necrotizing fasciitis and myositis due to betahemolytic

streptococcal infection

spreading cellulites and pain on motion of his right hip 2 weeks after
total colectomy

Classic dishwater edema of tissues with necrotic fascia

Right lower extremity after debridement of fascia to viable muscle

POST-OPERATIVE NOSOCOMIAL INFECTION

Most common PNI:
1. Urinary Tract Infection
2. Pneumonia
Most common complication within the first 2448 hours Atelectasis
Surgical Site infection occurs only in severe
infections
related to prolonged use of indwelling tubes
and catheters
UTI:
o Treatment for 3 to 5 days with a single
antibiotic
o Postoperative surgical patients should
have indwelling urinary catheters

removed ASAP, within 1 to 2 days if

patient is mobile
Pneumonia
o organisms are highly resistant to many
different agents
o hospital-acquired pneumonia: purulent
sputum, elevated leukocyte count, fever,
and new chest x-ray abnormality
o Surgical patients should be weaned from
mechanical ventilation as soon as feasible
Infection associated with indwelling
intravascular catheters
o Used for physiologic monitoring, vascular
access, drug delivery, and
hyperalimentation
o Many are asymptomatic
o Recommendations: use of antibioticbonded catheters, routine scheduled
catheter changes
SEPSIS
Patients presenting with severe sepsis should
receive :
1. Resuscitation fluids to maintain:
o central venous pressure target of 8 to 12
mmHg
o mean arterial pressure of > or equal to 65
mmHg
o urine output of 0.5 mL/kg per hour or
greater
2. Early empiric antibiotic therapy
3. Early identification and treatment of septic
sources is key for improved outcomes in
patients with sepsis
4. Use of vasopressors and inotropes
BIOLOGICAL WARFARE AGENTS
Concern remains that these agents could be
used as alternatives to nuclear weapons as
weapons of mass destruction as they are
relatively inexpensive
Spread via inhalation route most efficient
mode of mass exposure
1. Anthracis (Anthrax)
Incubation period: 1-6 days
Malaise, myalgia and fever
Chest x-ray findings: widened mediastinum,
pleural effusion
over a short period of time, symptoms
worsen, with development of respiratory
distress, chest pain and diaphoresis
high mortality rate
8

Treatment: combination therapy of

Clindamycin, Ciprofloxacin, Rifampicin
2. Yersinia pestis (Plague)
first biological warfare agent Crimean War
transmitted via flea bites from rodents
Clinical manifestations: epidemic
pneumonia with blood-tinged sputum,
fever, severe malaise
Treatment: aminoglycosides, doxycycline,
ciprofloxacin and chloramphenicol
3. Smallpox
Causative agent: Variola
- major cause of infectious morbidity and
mortality until its eradication in the 1970s
Incubation period: 10-12 days
Manifestations: fever, malaise, headache,
vomiting followed by centripetal rash (face
and extremities)
Treatment: Cidofovir acyclic nucleoside
phosphonate analogue
4. Francisella tularensis (Tularemia)
Tick - principal reservoir of this gramnegative aerobic organism
high infectivity after aerosolization
demonstrate pneumonia on chest x-ray
Treatment: aminoglycosides or second-line
agents such as doxycycline and
ciprofloxacin
KEYPOINTS: (Schwartz)
1. The incidence of surgical site infections can be
reduced by appropriate patient preparation,
timely perioperative antibiotic administration,
maintenance of perioperative normothermia and
normoglycemia, and appropriate wound
management.
2. Principles relevant to appropriate antibiotic
prophylaxis for surgery:
(a) select an agent with activity against common
organisms at the site of surgery,
(b) the initial dose of the antibiotic should be given
within 30 minutes of incision,
(c) antibiotics should be redosed every 1 to 2 halflives during surgery to ensure adequate tissue
levels, and
(d) antibiotics should not be continued for more
than 24 hours after surgery for routine
prophylaxis.

3. Source control is a key concept in the treatment

of most surgically relevant infections. Infected or
necrotic material must be drained or removed as

part of the treatment plan in this setting. Delays

in adequate source control are associated with
worsened outcomes.
4. Sepsis is both the presence of infection and the
host response to infection. Sepsis is a clinical
spectrum, ranging from sepsis (SIRS plus
infection) to severe sepsis (organ dysfunction), to
septic shock (hypotension requiring
vasopressors). Outcomes in patients with sepsis
are improved with an organized approach to
therapy that includes rapid resuscitation,
antibiotics, and source control.
5. When using antimicrobial agents for therapy of
serious infection, several principles should be
followed:
(a) Identify likely sources of infection,
(b) Choose an agent/s that covers likely organisms
for these sources,
(c) Remember that inadequate or delayed antibiotic
therapy results in increased mortality, so it is
important to begin therapy with broader
coverage,
(d) When possible, obtain cultures early and use
results to tailor therapy,
(e) If there is no infection identified after 3 days,
strongly consider discontinuation of antibiotics,
and
(f) stop antibiotics after an appropriate course of
therapy.

6. The keys to good outcomes in patients with

necrotizing soft tissue infection are early
recognition and appropriate debridement of
infected tissue with repeated debridement until
no further signs of infection are present.
7. Transmission of HIV and other infections spread
by blood and body fluid from patient to health
care worker can be minimized by observation of
universal precautions, which include routine use
of barriers when anticipating contact with blood
or body fluids, washing of hands and other skin
surfaces immediately after contact with blood or
body fluids, and careful handling and disposal of
sharp instruments during and after use.
References:
Lecture audio (texts in italic
are also taken from audio)
Schwartz Principles of
th
Surgery 9 Ed, Chapter 6
Powerpoint presentation
ACS Surgery: Principles and
Practice 6th Ed
Notetakers: Noel, Iah, Brian, Reulyssa, Yves