MANAGEMENT

OF
WOUND INFECTION

Wound infection has always been a major

complication of surgery and trauma.
The infection of wound can be defined as
the invasion of organisms through tissues
following breakdown of local and systemic
host defence leading to cellulitis, lymphangitis ,
abscess and bacteraemia .
Microorganisms are normally prevented
from causing infection by intact epithelial
surface, most notably the skin, these surfaces
are breakdown by trauma or surgery.

 In addition to these mechanical barrier there

are other protective mechanisms and can be
divided into
chemical low gastric pH
humoral antibodies, opsonins and
complements
cellular phagocytic cells , macrophages and
PMNL cells
All these protective mechanisms may be
compromised by surgical intervention or
trauma..
REDUCE RESISTANCE TO INFECTION HAS
SEVERAL CAUSES==

OLD AGE
IMMUNOSUPPRESSION
OBESITY
DM
MALNUTRITION
PERIPHERAL VASCULAR DISEASE
ANAEMIA
REDIATION EXPOSURE
RECENT TRAUMA
LOCAL TISSUE NECROSIS

 ORGANISMS RESPONSIBLE FOR WOUND

INFECTION
GRAM POSITIVE AEROBIC COCCI===
Staphylococcus aureus
S. epidermidis
S pyogens
S pneumoniae
Gram negative aerobic bacilli
E coli
H. influenzae
K. pneumoniae
P. mirabilis
. P. aeruginosa

Gram positive anaerobes

Cl. Perfringes
Cl. Tetani
Cl. Septicum
Cl. Difficile
Gram negative anaerobes
Fusobacterium spp
Bacteroids
Fungus
Aspergillus
Candida albicans
Cryptococcus
Histoplasma capsulatum

VIRUSES
Cytomegalovirus
Eb virus
HIV
Variocella virus
Hepatitis B and C virus

MANAGEMENT
Suppurative wound infection usually take 710 days to develop and even cellulitis around
the wound caused by invasive organisms
( beta haemolytic streptococcus) takes 3-4
days to develop.
If an infected wound is under tension or
there is any evidence of suppuration , suture
or clips need to be removed with curettage if
necessary to allow the pus to drain freely.

 In severely contaminated wounds such as an

incision made for drainage of an abscess is
logical to leave the skin open.
Delayed primary or secondary suture can be
undertaken when wound is clean and
granulating.
When taking pus from an infected wound
specimen should be send for microbiological
examination.

PRE OPERATIVE PREPARATION

Short pre operative hospital stay will reduce the the
risk of aquiring MRSA OR MRCNS or other HAIS
Every medical and nurshing staff should wash their
hands after any patient contact.
Alcoholic hand gel can be use but it do not destroy the
spore of cl difficile which may cause
pseudomembrenous colitis..
Staff with open infected wound should not enter in OT
Pre operative skin shaving should be undertaken in OT
Immediately before the surgery, as the infection rate
after clean wound surgery may be doubled if it is
performed the night before the surgery as minor skin
injury enhances bacterial colonisation..hair clipping is
best with lowest rate of infection

SCRUBBING AND SKIN PREPRATION

Aqous antiseptic should be use for hand
washing.
One application of alcoholic antiseptic is
adequate for skin prepration of surgical site.
This leads to 95% reduction in bacterial
count.
Number of staff and movement of staff in
and outside of OT should be kept minimum.

COMMONLY USED ANTISEPTICS

Chlorohexidine:-- use for skin preparation..
Effective against gram positive organisms and
stable in presence of pus and body fluids
Providone iodine :--use for skin preparation and
surgical scrubbing in dilute solution in open
wounds
Cetrimide :---for hand washing, instrument and
surface cleaning
Alcohol( 70% ethyl and isopropyl alcohol):---skin
prepration
Hexachlorophene:----for skin prepration and hand
washing.. Action against gram negative organisms.

PROPHYLACTIC ANTIBIOTICS FOR

WOUND INFECTION

If antibiotics are given to prevent infection

after surgery or instrumentation they should be
used when local wound defence are not
established..
Ideally maximum blood and tissue level should
be present at the time at which the first
incision is made..
In long standing procedures when there is
excessive blood loss or when unexpected
contamination occurs antibiotic may be
repeated at 4 hourly interval during surgery..

 Choice of antibiotic depends on expected spectrum

of organisms likely to be encountered
VASCULAR SURGERY===
organisms encountered s. epidermidis
s. aureus
aerobic gm neg bacilli
Drug of choice one dose of amoxycillin + clavulinic
acid with or without gentamicin or vancomycin.
ORTHOPEDICS SURGERY===
organisms encountered- s.epidermidis
s. aureus
drugs of choice one dose of amoxycillin +
clavulinic acid.

OESOPHAGO GASTRIC SURGERIES===

organisms encountered-- enterococci
including anaerobic and viridans streptococci
Drug of choice---one dose of second
generation cephalosporin and metronidazole
in severe contamination
BILLIARY SURGERIES=====
organisms encountered--- E . Coli and
streptococcus fecalis
drug of choice-- one dose of 2nd gen.
cephalosporins

SMALL BOWEL SURGERY====

organisms encountered--- enterobacteriace and
bacteroids
Drug of choice----one dose of 2nd generation
cephalosporin with or without metronidazole

ANTIBIOTICS USED IN TREATMENT AND

PROPHYLAXIS
==PENICILLIN==
Most effective against gm positive pathogens
includinng streptococci, clostridia and some
staphylococci dont produce beta lactamase .
Till effective against actinomyces.
All serious infection including gas gangrene
require high dose of benzyl penicillin.

 FLUCLOXACILLIN
a beta lactamase resistant penicillin and is therefore
used in treating most community acquired
staphylococci infection
AMPICILLIN AND AMOXYCILLIN
Effective against enterobacteriace , enterococcus and
group D streptococci
MEZLOCILLIN AND AZLOCILLIN
Effective against enterobactor and klebsiella
Azlocillin effective against pseudomonas
having some activity against bacteroids and enterococci
combination of both is useful for treatment of
mixed infection caused by gram negative organisms
in immunocompromised patients

CEPHALOSPORINS
Cefuroxime , cefotaxime, ceftazidime are
widely used.

the first two are effective against

intraabdomonal skin and soft tissue infection
ceftazidine is effective against gram negative
organisms , s aureus and pseudomonas
aeruginosa
Cephalosporins may be combined with
metronidazole or aminoglycosides if anaerobic
cover is necessary

AMINOGLYCOSIDES
Gentamicin and tobramycin are effective
against gram negative enterobacteriace..
Gentamicin is effective against pseudomas.
Ototoxic and nephrotoxic
VANCOMYCIN
Effective against gm positive bacteria and
against MRSA.
Also effective against cl. Deficille
Ototoxic and nephrotoxic

IMIDAZOLE
Metronidazole is widely used.
Active against anaerobes
infection caused by anaerobic cocci, strains
of bacteroides and clostridia can be treated
Useful for prophylaxis of anaerobic infection
after abdominal, colorectal and pelvic surgery

 CARBAPENAM
IMEPENAM, MEROPENAM, ERTAPENAM
are stable to beta lactamase
Have useful broad spectrum anaerobic as
well as gm positive activity and effective for
treatment of resistant organisms

THANK
YOU