Surgical infection

Definition Determination of infection Type of Surgical Wound Infection Surgical site infection Organ-Specific Infections Intra-Abdominal Infections Infections of the skin and soft tissue Postoperative Nosocomial Infection Antimicrobial Therapy

Definition
Surgical infection ; Infections that require operative treatment such as
Necrotizing soft tissue infection Body cavity infection Empyema Abscess Surgical wound infection Postoperative Abscess Hospital Acquired Infection Pneumonia Urinary Tract Infection Vascular-related infection

or complication of surgical treatment such as

Important Definitions
Contamination
Transient exposure of a wound to bacteria Varying concentrations of bacteria possible Time of exposure suggested to be < 6 hours SSI prophylaxis best strategy

Important Definitions (cont.)

Infection
Systemic and local signs of inflammation Bacterial counts 105 cfu/mL Purulent versus nonpurulent

Colonization
Bacteria present in a wound with no signs or symptoms of systemic inflammation Usually less than 105 cfu/mL

Determination of infection
Host Defenses Microbial Pathogenicity Local Environment Surgical Technique

Determination of infection

Host Defenses

Host Defenses

Host Defenses
Patients with alteration of their normal flora are at risk for infection. Prior antibiotic use eliminates normal resident flora, opening the field for overgrowth of opportunistic pathogens. Patients on H2-blockers may have bacterial colonization of the stomach, thus increasing the risk of pneumonia following aspiration of gastric contents. Patients with peripheral vascular disease, hypovolemic shock, systemic hypoxemia, or vasoconstricting medications are at risk for infection due to decreased blood flow and decreased peripheral oxygen tension.

Host Defenses
Certain host factors significantly increase the ability of microorganisms to invade. Patients at - extremes of age - using steroids - cancer - burns - trauma - diabetes - malnutrition - uremia - inherited or acquired immunocompromise That all have diminished humoral defenses putting them at risk for infection.

Microbial Pathogenicity
Microbial factors of importance include
Number (inoculum size) and types of microbes Rate of microbial proliferation Microbial virulence factors such as
Ability to produce toxins (exotoxins/endotoxins) Ability to resist phagocytosis and intracellular destruction

Susceptible host

Microbial Pathogenicity
Bacteria
Aerobes Anaerobes Gram positive/negative Other bacteria

Common Autochthonous Microbes in Various Parts of the Body.

Fungi Virus

Local Environment
Foreign body ex. Suture material Necrotic tissue, hematoma, seroma, tissue edema >>> decrease phagocytic activity Shock, Peripheral vascular disease >>> decrease Blood supply >>> decrease host defense

Surgical Technique
Good surgical technique is essential to a good outcome. Tissue should be handled gently to preserve circulation, as crushed tissue may become devitalized. Debride devitalized tissue, remove foreign bodies, and limit amount of suture in the deep closure. Seroma, hematoma, and dead space should be drained

Relationship between sepsis and systemic response

Type of Surgical Infection

Infections of Significance in Surgical Patients Surgical site infection Organ-Specific Infections Intra-Abdominal Infections Infections of the Skin and Soft Tissue Postoperative Nosocomial Infections

Postoperative Nosocomial Infections

Nosocomial infection (NI) is defined as an infection that is not present or incubating when the patient is admitted to a hospital or other health care facility. discovered 48-72h after admission is indicative of nosocomial frequently associated with drug-resistant microorganisms, including methicillin-resistant Staphylococcus aureus (MRSA), resistant gram negatives such as Acinetobacter and Candida species.

Postoperative Nosocomial Infections

nosocomial infections are related to prolonged use of indwelling tubes and catheters for the purpose of urinary drainage, ventilation, and venous and arterial access
- Wound infection - Urinary tract infection (most common) - Lower respiratory tract infection - Vascular catheter-related infection

Urinary Tract Infections

increase risk in indwelling urinary catheter UA : WBC, bacteria, positive leukocyte esterase Diagnosis : urine culture 10 4 CFU /ml in symptomatic patients 10 5 CFU /ml in asymptomatic patients Treatment : antibiotics 10-14 days Post-op : indwelling urinary catheters removed as quickly as possible

Pneumonia
Prolonged mechanical ventilation is associated with an increased incidence of pneumonia Diagnosis is established based on roentgenographic (CXR) bronchoalveolar lavage ; Gram's stain and to performing a culture to assess for the presence of microbes. Surgical patients should be weaned from mechanical ventilation as soon as feasible, based on oxygenation and inspiratory effort.

DIAGNOSTIC STRATEGIES
Pneumonia is commonly clinically defined as the presence of a new, persistent pulmonary infiltrate not otherwise explained on chest radiographs in combination with at least two criteria, including
(1) temperature of greater than 38.3C, (2) leukocytosis of greater than 10,000 cells/mm (3) purulent respiratory secretions

Jeffrey A. Norton et al., Surgery Basic Science and Clinical Evidence. 2nd ed 2008

Intravascular catheter
Condition that increase the risk of infection ; 1. Prolonged insertion 2. Insertion under emergency conditions 3. Manipulation under non-sterile conditions 4. use of multi-lumen catheters

Postoperative fever
The etiology of fever occurring within 3 postoperative days is usually noninfectious. When thinking about a patient with postoperative fever, remember the 5 Ws: wind, water, walk, wound, and wonder drug.

ETIOLOGY OF POSTOPERATIVE FEVER AND INFECTION

POD 1-2 : Wind : Atelectasis POD 3-5 : Water : Urinary tract infections POD 4-6 : Walking : Deep venous thrombosis POD 5-7 : Wound : Most wound infections occur during this period POD 7+ : Wonder drugs : Drugs can cause fevers

Diagnosis and Treatment of Surgical Infection

The most important part of the evaluation of pt. suspected of having a surgical infection is careful history and PE Laboratory and radiological technique: Urinalysis, CBC, blood culture, Gram stain & Culture of Wound , Sputum and sensitivity Imaging ; X-ray, U/S, CT, MRI

Diagnosis and Treatment of Surgical Infection

If w/ Pus (color, Odor and Consistency) Foul odor Anaerobic Greenish P. aeruginosa Creamy S. aureus Thin watery Strep / clostridium

Primary principle of surgical treatment of surgical infection are: 1. Incision and drain of localized abscess 2. Adequate debridement of necrotic tisue 3. Removal of all hematomas, seroma and foreign bodies 4. If with dead space ---> put sterile close suction tube