Divertasi infeksi pada

bedah
Hendy Buana Vijaya
 Surgical Site Infections
SSIs are infections of the tissues, organs, or spaces exposed by surgeons
during performance of an invasive procedure.
SSIs are classified into
• Incisional:
a. superficial (limited to skin and subcutaneous tissue)
b. deep incisional categories
• Organ/space infections
 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 and sensitivity
 Ultrasonography / CT scan / MRI
Diagnosis and Treatment of Surgical Infection

Secara umum gambaran klinis pada luka infeksi

• Foul odor - Anaerobic
• Greenish - P. aeruginosa
• Creamy - S. aureus
• Thin watery - Strep / clostridium
 Surgical Intervention

Primary principle of surgical treatment of surgical infection are:

• Incision and drain of localized abscess
• Adequate debridement of necrotic tisue
• Removal of all hematomas, seroma and foreign bodies
• If with dead space ---> put sterile close suction tube
• Antibiotic in invasive infections
 Non-Specific Acute Infection
• Postoperative Wound Infection / Surgical site infections
• Cellulitisdan Erysipelas
• Acute Lymphangitis and Lymphadenitis
• Furuncle dan Carbuncle
• Acute Abscess
• Bacteraemia and Septicaemia
 Specific Acute Infections
• Tetanus
• Gas Gangrene
• Necrotizing Fasciitis
Cross Section of Abdominal Wall
Depicting CDC SSI Classifications
 Superficial Incisional SSI
Infection occurs within 30 days after the
operation and involves only skin or Skin
subcutaneous tissue Superficial
incisional SSI
of the incision
Subcutaneous
tissue

Mangram AJ et al. Infect Control Hosp Epidemiol. 1999;20:250-278.

 Deep Incisional SSI
Infection occurs within 30 days after
the operation if no implant is left in
place or within 3 months if implant Superficial
is in place and the infection appears incisional SSI
to be related to the operation and
the infection involves the deep soft
tissue (e.g., fascia and muscle layers)

Deep soft tissue Deep incisional

(fascia & muscle) SSI
 Organ/Space SSI
Superficial
incisional SSI
Infection occurs within 30 days after the
operation if no implant is left in place or
within 3months if implant is in place and the
infection appears to be related to the
operation and the infection involves any part
Deep incisional
of the anatomy, other than the incision, SSI
which was opened or manipulated during the
operation

Organ/space Organ/space SSI

Mangram AJ et al. Infect Control Hosp Epidemiol.

1999;20:250-278.
 Cellulitis
• Erythema, local pain & tenderness, edema
• Fever, chills, malaise and toxic reaction
• Pathogens:
1. Streptococcus pyogenes
2. Staphylococcus aureus
3. Streptococcus pneumoniae
4. Haemophilus influenzae
5. Aerobic and anaerobic gram (-)
• Tx: - antibiotic, immobilization / elevation and hygiene
Celulitis
 Furuncle dan karbunkel

• Is a staphylococcal infection of a hair follicle

or a sebaceous gland.
• The common sites:
face, neck and axilla.
• Common in diabetics.
 Clinical Picture
A small painful indurated swelling which is
- red
- hot
- and very tender
Treatment :
- Antibiotic
- Drainage
 Carbuncle
• Is infective gangrene of the subcutaneous tissues usually secondary to
infection by Staphylococcus aureus.
• It is common in immunocompromised patients as in diabetics.
• The common sites:
face, nape of the neck, and the back
 Pathology
• Infection usually starts in a hair follicle
• Extends to the subcutaneous fat where other hair follicles get the infection.
• Multiple areas of necrosis and thrombosis of blood vessels occur.
• Patches of skin undergo sloughing and separate from the underlying
granulation tissue
 Clinical Picture
• There is usually sever toxemia.
• Starts as a painful induration of the skin and subcutaneous tissues.
• The skin is red.
• Swelling its central part becomes soft.
• Multiple areas of skin thin out and separate forming multiple sinuses.
 Treatment
1.Antibiotics.

2.culture and sensitivity of the discharge.

3.control of diabetes.

4.surgical excision of sloughs.

 Hydradenitis Suppurativa
Mixed staph. And streptococcal infection
of the apocrine sweat glands, in the
perineum or the axilla,produces multiple
abscesses and pus discharging sinuses.
 Treatment

• Surgical drainage of abscesses.

• Antiseptic and antifungal applications.

• Surgical excision of the apocrine sweat-bearing skin following by skin

grafting is essential.
 Acute Abscess
• It is a localized suppurative inflammation.
• It is caused by pyogenic organisms.
• The commonest are staphylococci that produce a coagulase enzyme.
 Pathogenesis
The organism reach the tissues by :
- direct access through wounds, scratches and abrasions.
- local extension from an adjacent focus
- lymphatic spread.
- blood spread.
 Pathology
An abscess consists of three zones:
1- A central zone of coagulative necrosis

2- An intermediate zone of granulation tissue.

3- A peripheral zone of acute inflammation.

 Acute Lymphangitis and Lyphadenitis
• Acute lymphangitis:is due to infection of lymph vessels by organisms usually
streptococci.
• Acute lymphadenitis: is due to spread of infection along lymphatics from a
septic focus in the drainage area to the lymph- nodes.
 Treatment
• Antibiotics.
• Hot applications.
• Surgical drainage if suppuration occurs.
Specific Acute Infections
 Tetanus
Etiology : Clostridium tetany (Anaerobic Gram +)
o Tetanospasm – acts on the anterior horn cells of spinal cord and
brain stem by blocking the inhibitor synapses
o Tetanolysin - cardiotoxic and hemolysis
Manifestation :
o Restlessness , headache, stiff neck, difficulty of swallowing
o Orthotonus, opisthotonus, convulsion
 Treatment
• Neutralize toxin with TIG.
• Wound debridment.
• Avoid sudden stimuli.
• Muscle relaxant with mechanical ventilation may require tracheostomy.
• Aqueous penicillin G ,10-40 million units a day IV.
• Nursing.
 Gas Gangrene

It is an acute spreading infection associated with gas formation and profound

toxemia caused by anaerobic spore-bearing bacilli of the clostridium group.
 Organisms falls into two groups:
Saccharolytic organisms:
Cl. welchii, Cl.septicum, Cl. oedematiens
Proteolytic organisms:
Cl. sporogenes,-Cl. histolyticum and Cl. tertium
• -pain and numbness in the affected
area. -
swelling and there may be crepitus with
gas bubbles.
-A sanguineous dischrge of a
characteristic odour.
-The affected muscles brick red then
greenish and finally black
discolouration,do not contract,do not
bleed if cut, the skin black.
 Prevention Treatment

• Wound management.
• Adequate debridement of wounds.
• Hyperbaric oxygenation.
• Antibiotics.
• Antibiotics: penecillin.
• Avoid tissue hypoxia.
 Necrotizing Soft Tissue Infections:

• They can be defined as infections of any of the layers within the

soft tissue compartment (dermis, subcutaneous tissue, superficial
fascia, deep fascia, or muscle) that are associated with necrotizing
changes
• Necrotizing fascitis, Strep. Gangrene, Clostridium myonecrosis and
Fournier’s gangrene
• Mixed aerobic and anaerobic gram negative and gram positive
bacteria as well as fungi
• Patients at risk : elderly, immunosuppressed,
diabetic, peripheral vascular disease, or those
with a combination of these factors.
• most commonly affected: extremities,
perineum, trunk, and torso
Necrotizing
 Manifestation

• small break or sinus in the skin from which grayish, turbid

semipurulent material ("dishwater pus") can be expressed
• skin changes (bronze hue or brawny induration), blebs, or crepitus
• pain at the site of infection that appears to be out of proportion to
any of the physical manifestations
• sepsis syndrome or septic shock
 Treatment

• Antimicrobial agents directed against gram-positive and

gram-negative aerobes and anaerobes (e.g., vancomycin
plus a carbapenem), as well as high-dose aqueous penicillin
G (16,000 to 20,000 U/d for clostridial pathogens
• Antibiotic therapy can be refined based on culture and
sensitivity results, particularly in the case of monomicrobial
soft tissue infections.
Terima kasih