Surgical Infection

By Mohammed Al Mayuof

Wael Al ZhraniHossam ShabiFiras Al sololey

Content • Common Surgical Infection

• Management of Surgical Infection

• Wound Infection

• Management of Wound Infection

Surgical infection • Cellulitis• Erysipelas• Lymphangitis• Boil (Furuncle)• Carbuncle • Hidradenitis suppurativa• Necrotizing fasciitis• Gas gangrene

Cellulitis• Diffuse inflammation of connective tissue

with severe inflammation of dermal and subcutaneous layers of the skin.

• Group A streptococcus and staphylococcus are the most common of these bacteria

• Red, hot, and tender.• Fever and malaise maybe present.• Cellulitis is most often a clinical diagnosis

Cellulitis

Erysipelas• acute streptococcus bacterial infection of the

dermis, resulting in inflammation.

• red, swollen, warm, hardened and painful rash .

• face, arms, fingers, legs and toes.

• high fevers, shaking, chills, fatigue, headaches, vomitting, and general illness .

• Streptococcus pyogenes (Group A streptococcus)

Erysipelas

Lymphangitis• Non-suppurative infection of the lymphatic

channels that occurs as a result of infection at a site distal to the channel.

• Red tender streaks in the line of lymphatics.

• chills and a high fever along with moderate pain and swelling .

• Streptococcus pyogenes

Lymphangitis

Boil (Furuncle) • deep infective folliculitis• bumpy red, pus-filled lumps around a hair follicle that

are tender, warm, and very painful• In a severe infection, an individual may experience

fever, swollen lymph nodes, and fatigue• staphylococcus aureus• furunculosis• bacterial carriage in the nostrils, DM, obesity,

lymphoprolefrative neoplasm, malnutrition, and use of immunosuppressive drugs.

Boil (Furuncle)

Carbuncle • abscess larger than a boil, usually with one or more

openings draining pus onto the skin.

• Dissects through dermis and subcutaneous tissue.

• back and the nape of the neck .

• grow very fast and have a white or yellow center.

• Red, tender, fatigue, fever and a general sickness.

• itching may occur before the carbuncle develops.

Carbuncle

Hidradenitis suppurativa• Skin disease that most commonly affects areas

bearing apocrine sweat glands or sebaceous glands

• underarms, breasts, inner thighs, groin and buttocks

• Indurated, fibrotic, inflamed with sinuses draining pus.

• Bacterial infection, androgen dysfunction, excessive sweating, Plugged apocrine…..

• Squamous cell carcinoma, contractures, anal, rectal, or urethral fistula….

Hidradenitis suppurativa

Necrotizing fasciitis• flesh-eating disease or Flesh-eating bacteria

syndrome• Rare infection of the deeper layers of skin and

subcutaneous tissue, easily spreading across the fascial plane within the subcutaneous tissue.

• infection begins locally, redness and swollen or hot skin, spread very quickly.

• Skin color may progress to violet, and blisters may form, with subsequent necrosis of the subcutaneous tissue.

• Streptococci, staph, coliforms, anerobs

Necrotizing fasciitis

Gas gangrene• Bacterial infection that produces gas in gangrene .

• myonecrosis, gas production, and sepsis.

• Sever pain, swollen tissue, brownish serous malodorous fluid, and patchy necrosis.

• Progression to toxemia and shock is often very rapid .

• Clostridium perfringens

Gas gangrene

Management of Surgical Infections

Cellulitis Investigation :Wbc and blood culture .

Treatment :The usual organism is streptococcus that is usually sensitive to penicillin.

Immobilization and elevation of a limb may be required.

Occasionally and abscess with watery pus forms and reqired drainage.

Erysipelas

Depending on the severity, treatment involves either oral or intravenous antibiotics, using penicillins, clindamycin or erythromycin.

Because of the risk of reinfection, prophylactic antibiotics are sometimes used after resolution of the initial condition

LymphangitisInvestigation:Wbc and blood culture.

Treatment:If accompanying cellulitis , treat with penicillin.

Lymphadenitis may follow various types of infection in the sites drained by the nodes.

Treatment depends upon isolation of the infecting organism.

Boil (furuncle)Investigations:

Blood cultures , wbc

Treatment: All furuncles must drain in order to heal. Draining can be

encouraged by application of a cloth soaked in warm salt water. Washing and covering the furuncle with antibiotic cream or antiseptic tea tree oil and a bandage also promotes healing .

Carbuncle

Carbuncles usually must drain before they will heal. This

most often occurs on its own in less than two weeks.

Treatment is needed if the carbuncle lasts longer than

two weeks.

Treatment is with antistaphylococcal antibiotics eg, flucloxacillin with desloughing and adecuate drainage of the abscesses if necessary.

Hidradenitis suppurativa

Treatment:Treatment is initially by antibiotics

and the Abscesses are incised and drained.

Advanced cases may need wide excision and grafting.

Severe perianal disease may required a diverting colostomy prior to skin grafting.

Necrotizing fascitisInvestigations : wbc , blood cultures , swabs and radiograph may

show gas in tissues .Treatment:

Remove all infected and dead tissue . The tissue usually oedematous , gray and smells .

Treatment is usually with penicillin and gentamicin intravenously . The wound is inspected regularly

and any further necrotic tissue excised.

Gas gangrene

Investigations :

Wbc , bilirubin raised because of haemolysis , gram stain of discharge shows gram positive

bacilli and radiograph shows gas in tissue.

Gas gangrene Treatment:

Prophylactic : adequate debridement of wound at time of initial injury .

All contused and dead tissue should be removed and the wound thoroughly irrigated and left open .

Prophylactic penicillin should be given to all patients with contaminated wounds .

Gas gangrene Therapeutic :

Radical debridement of all necrotic tissue is mandatory . If the muscle of a limb is involved, amputation will be necessary and large dose of penicillin should

be given intravenously .

WOUND INFECTION

DefinitionSuperficial incisional infection:Infection involves only skin and subcutaneous tissue of

incision.

Deep incisional infections:Infection involves deep tissues, such as fascial and

muscle layers.

Organ infections:Infection involves any part of the anatomy in organs

and spaces other than the incision, which was opened or manipulated during operation.

Predisposing Factors General 1- Poor general condition

(age,malnutrition,obesity,smoking, alcohlism) 2- Systemic disease

(diabets,hypertension,CRF,…….) 3- Drugs that cause immunosuppression

Local : 1- Poor blood supply . 2- Poor surgical technique . 3- Presence of foreign bodies . 4- Nature of the operation . 5- Defect in sterilization technique in the operating theatre .

Classification• Clean (Class I) :Uninfected operative wound .

No acute inflammation . No entered respiratory, gastrointestinal, biliary, and urinary

tracts.

No need for prophylaxis .

The risk of postoperatve wound infecton is around 2%.

Classification• Clean-contaminated (Class II) :

suspicion of presence of infection .

Elective entry into respiratory, biliary, gastrointestinal, urinary tracts .

Prophylaxis is advisable .

risk of infecton is about 5-10%.

Classification• Contaminated (Class III) :

Surgery where microorganisms are definitely present .

Prophylaxis is advisable .

risk of infecton is up to 20% .

Classification• Dirty-infected (Class IV) :

Surgery through a well established infection .

The use of antibiotic is considered to be of therapeutic nature .

The risk of infecton is up to 50%.

Clinical Picture

Wound infection usually appears between the fifth and tenth days postoperative .

* Fever * Pain in the wound

Signs: _ swollen _tenderness

_redness _fluctuant

Management of Surgical Wound Infection

Prevention of Surgical Wound Infection

General measures• Proper technique of the surgeon and surgical

team :

1. Monofilament sutures.2. Minimize sutures and ligatures.3. Do not strangulate tissues.4. Meticulous skin closure.

• Vigilance for breaks in aseptic technique .

• The general health and disease state of the patient.

• Patient hygiene (hair removal ,antimicrobial shower)

• Decrease hospital stay.

• Immunological status of the patient.

• Avoidance of post operative hypoxia.

• Early surveillance of wound.

Prophylactic Antibiotics• Indications:

• Traumatic wound with contamination , delay of tx, injury to hollow viscus.

• Clean –contaminated and contaminated operations.• Resection or anastomosis of colon or intestine.• Presence or application of prosthetic device.• Valvular heart disease.• Shock.• Immunocompromised patient.• Presence of ischemic tissue.• Open fractures, penetrating joint injury.

Examples:

• Antibiotic Prophylaxis before Elective Colon Resection

• both antibiotics and mechanical methods are used.

• Three regimens of oral agents combine neomycin with erythromycin base, metronidazole, or tetracycline.

• Antibiotic Prophylaxis for Appendectomy

• The pathologic state of the appendix is the most important determinant of postoperative infection .

• But because the pathologic state of the appendix often cannot be determined before or during operation, a parenteral antibiotic agent is recommended as prophylaxis in all patients.

• Regimens with activity against both facultative gram-negative bacilli and anaerobes .

• In perforated appendicitis antibiotics are considered therapeutic rather than prophylactic.

• Preventive Antibiotics in Penetrating Abdominal Trauma

• A single dose of parenterally administered antibiotic, given just before abdominal exploration for penetrating abdominal trauma is practiced.

• If gastrointestinal leakage is identified, continuing the antibiotic agents for 1 to 3 days is usually recommended.

• Preventive Antibiotic Use in Traumatic Chest Injuries

• cefazolin is given intravenously every 8 hours for 24 hours .

Management of Surgical Wound Infection

• Generally;

• Left open when contaminated.

• Dressing.

• Keep moist to dry.

• Change twice daily at least.

• Antibiotics (general or specific).

Algorithm

Notify the surgeon

• < 48 hours• wound inflammation• +/- fever

• Wound infection unlikely, but: consider rapidly progressive infection clostridial or mixed anaerobic or streptococcal

if likely:

• urgent surgical consult• c/s• administer first dose of (IV) antibiotics before transport:Penicillin Clindamycin

or Cefazolin

MetronidazoleFor Type I ß-lactam allergy:

Vancomycin Metronidazole

• > 48 hours• wound inflammation / indurations• +/- fever• +/- tachycardia

• consider open wound (C&S)• consider U/S to rule out abscess

• Clean wound• Give (IV) antibiotics:

• Cefazolin• For Type I ß-lactam allergy:• Clindamycin• or• Vancomycin

• Wound of perineum OR operation on GI/GU Tract• Cefazolin + Metronidazole• For Type I ß-lactam allergy:• Clindamycin + Ciprofloxacin

or• Vancomycin + Cipro + Metronidazole

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