SURGICAL INFECTIONS

By Dr. Ahmed Mustafa

SURGICAL INFECTIONS

Infections that require surgical treatment or related to operative interventions

SURGICAL INFECTIONS

Infections required surgical treatment Necrotizing soft tissue infections Infections of body cavities (peritonitis, empyema, etc.) Infections confined to an organ or tissue (abscesses, septic arthritis, cholecystitis, etc) Prosthetic device infections

SURGICAL INFECTIONS
INFECTIONS RELATED TO OPERATIVE INTERVENTION Wound infections - Surgical site infections Postoperative infections (peritonitis or other cavity infections) Surgical nosocomial infections (pneumonia, urinary tract infections, catheter infections)

NOSOCOMIAL INFECTIONS

Occurs after the initial 48 hours of admission Urinary tract infection (IV) Catheter-related infection Lower respiratory tract infection Infection via transfusion Bacteriemia and Sepsis

PATHOGENESIS

DETERMINANTS OF INFECTIONS Microorganism Host Defenses (virulance) (type&severity of immunosupression) INFECTION Environment (Fluids, foreign bodies, a closed unperfused space etc.)

Infectious agent

The Endogenous Gastrointestinal Microflora Stomach Duodenum Aerobes and anaerobes Proximal small bowel <104/mL Distal small bowel Enterobacteriaceae Enterococcus spp 103-108/mL Anaerobic organisms Colon Anaerobic organisms Bacteriodes fragilis 1012/mL

Microbiology of Intraabdominal Infections

Aerobes: Escerichia coli Klebsiella spp. Proteus spp Enterobacter spp Enterococcus spp Anaerobes: Bacteriodes spp Peptostreptococcus spp Clostridium spp Bilophila wadsworthia Fungi,Candida

HOST DEFENSE MECHANISMS

Nonspecific Surface Mechanical barrier (skin, mucosa) Secretory barrier Immunoglobulins Ciliary motion Movement

HOST DEFENSE MECHANISMS

Specific Cellular defense Phagocytic cells Cellmediated immunity (PNLs, eosinophils, mononuclear cells) (T lymphocytes & macrophages) Natural killer cells Humoral defense Lyzozyme Immunoglobulins Complement Interferon

A Susceptible host

Causes of Impaired Host Resistance to Infection Patients Underlying Condition AIDS Remote infection Neoplasia Malnutrition Acute stress (burns, trauma) Metabolic illness (DM, uremia) Aging Obesity Smoking

A Susceptible host

Iatrogenic Antineoplastic chemotherapy Immunosuppressive therapy (allograft recipients, autoimmune disorders) Splenectomy

Infection Environment

Wound or a natural space with narrow outlets

Fluids, foreign bodies, a closed unperfused space etc

Clinical finding
LOCAL MANIFESTATIONS OF SURGICAL INFECTIONS CELLULITIS: Spreading infection of the skin and subcutaneous tissue LYMPHANGITIS: Inflammation of the lymphatic channels in the subcutaneous tissue ABSCESS: Localized accumulation of purulent material situated in the dermis or subcutaneous tissue

SURGICAL SITE INFECTION

The term surgical site infection now replaces surgical wound infection Superficial incisional SSI; involves the skin or subcutaneous tissue Deep incisional SSI; involves the deep tissue such as fascia or muscle,Organ/space SSI

SURGICAL SITE INFECTION DEFINITION

Superficial Incisional Infection Any incisional infection occuring within postoperative 30 days at any level above fascia described as; Presence of any purulant discharge (culture may not reveal any opponent) Any positive culture findings from primarily closed incision Deleberate incision exploration Infection diagnosis determined by the surgeon

SURGICAL SITE INFECTION DEFINITION

Deep Incisional /Organ / Space Infection Any infection occuring within postoperative 30 days or within postoperative one year if any implant is left described as; Presence of any purulant discharge (through drains) Any positive culture findings from intraabdominal samples Spontaneous wound dehiscence Presence of abscess Infection diagnosis determined by the surgeon

Diagnosis

Redness Swelling Hyperthermia Fluctuation Purulent or turbid aspirate

OPERATIVE WOUNDS

NATIONAL RESEARCH COUNCIL CLASSIFICATION OF OPERATIVE WOUNDS

CLASSIFICATION OF OPERATIVE WOUNDS

CLEAN Nontraumatic No inflammation encountered No break in technique Respiratory, alimentary, genitourinary tracts not entered

CLASSIFICATION OF OPERATIVE WOUNDS

CLEAN CONTAMINATED Gastrointestinal or respiratory tracts entered without significant spillage 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

CLASSIFICATION OF OPERATIVE WOUNDS

CONTAMINATED Major break in technique Gross spillage from gastrointestinal tract Traumatic wound, fresh Entrance of genitourinary or biliary tracts in presence of infected urine or bile

CLASSIFICATION OF OPERATIVE WOUNDS

DIRTY and INFECTED Acute bacterial inflammation encountered, without pus Transection of clean tissue for the purpose of surgical access to a collection of pus Traumatic wound with retained devitalized tissue,foreign bodies, fecal contamination, and/or delayed treatment, or from dirty source.

Treatment

Principles of Antibiotic Therapy Why to use antibiotics? Where is infection? What are the most probable pathogens? How about antibiotic susceptibility? Pharmacological properties Is combination of antibiotics necessary? Host factors Monitoring accuracy of therapy