General surgery – 4th stage
Surgical infection صباح الهيت.د
Surgical infections : infections that require operative treatment or result from operative
treatment.
Infections that require operative treatment include:
● necrotizing soft tissue infections
● body cavity infections such as peritonitis, suppurative pericarditis and empyema.
● confined tissue, organ, or joint infections such as abscess and septic arthritis
● prosthetic device–associated infections e.g. infected plate used in fixation of fracture
infections that result from operative treatments include:
● wound infections,
● postoperative abscesses,
● postoperative body cavity infections such as postoperative peritonitis.
● prosthetic device– related infections,
● hospital-acquired infections such as pneumonia.
Determinants of Infection
The development of surgical infection depends on several factors:
(1) microbial pathogenicity and number,
(2) host defenses,
(3) the local environment: e.g a traumatic wound has greater likelihood if the trauma has
resulted in devitalization of tissue or if foreign bodies have been deposited in the wound.
(4) surgical technique: the surgeon can reduce the likelihood of postoperative infections by
handling tissues gently; removing devitalized tissues, blood and other substances that promote
growth of microbes; and using drains appropriately.
Types of surgical infections
Soft tissue infections include:
1- Cellulitis and lymphangitis: Cellulitis is a non-suppurative, invasive infection of tissues,
which is usually related to the point of injury.There is poor localisation in addition to the
cardinal signs of spreading inflammation (redness, heatness, swelling, pain and loss of
function). Systemic signs (the old-fashioned term is toxaemia) are common, with chills, fever
and rigors. These events follow the release of toxins into the circulation.
Lymphangitis is part of a similar process and presents as painful red streaks in affected
lymphatics draining the source of infection. Lymphangitis is often accompanied by painful
lymph node groups (lymphadenitis) in the related drainage area. Blood cultures are often
negative.
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General surgery – 4th stage
Treatment: antibiotics alone but Surgical incision and drainage are indicated if no improvement
is seen in 2 to 3 days, or if evidence of purulent collection is identified.
2- Soft tissue abscess:
An abscess is a pocket of tissue containing necrotic tissue, bacterial colonies, and dead white
cells.
The area of infection may or may not be fluctuant. The patient is often febrile at this stage.
Treatment: incision and drainage (I&D) and leave the cavity to heal by secondary intention.
Antibiotics should be used if the abscess cavity is closed after drainage.
3- Necrotizing Soft tissue infections ( gas gangrene, necrotizing fasciitis)
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. NSTIs are typically not associated with abscesses, although they can
originate from an untreated or inadequately drained abscess. Debridement of the necrotic
tissue should be undertaken as soon as possible together with other principles of treatment for
any kind of surgical infection: source control, antimicrobial therapy, support.
Antibiotics in surgical infections
A. Indications : is used only as adjunct in treating surgical infection; operative treatment is
more important. The antibiotics is used either for
I. Treatment of infection (Empiric treatment, Definitive treatment).
II. Prophylactic antibiotics
B. Principles of antibiotic treatment
I. Identify most likely causative organism (bacteria, fungus or virus)
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General surgery – 4th stage
II. Use appropriate antibiotic agents
III. Initially, start antibiotic treatment on presenting identifications and clinical
judgment.
IV. Assessment of renal and hepatic functions
V. Presence of hypersensitivity to drugs.
VI. Prior to treatment specimens of blood, urine should be collected.
VII. Pus should be drained
VIII. Necrotic tissue and foreign bodies should be removed.
IX. Once started AB. , should never be changed unless features of no responding by
clinical examinations or culture results show different pathogens.
X. Route of giving antibiotics
C. Complications of antibiotic treatment
I. Development of resistance.
II. Hypersensitivity.
III. Side and irritation effects.
IV. Opportunistic infections (disturbe normal flora).
V. Toxic effects
D. Indications of combined antibiotic treatment
I. Treatment of mixed infections.
II. To delay development of bacterial resistance.
III. Initial treatment of serious infections.
IV. To obtain potentiation or synergistic actions
E. Causes of ineffective antibiotic treatment
I. Wrong route of administration.
II. Impaired host defence mechanism.
III. Abscess not adequately drained.
IV. Presence of foreign body.
V. Delay in initiation of treatment.
VI. Improper dose given
F. What are the indications for prophylactic antibiotics?
I. when bacterial contamination of the wound is high(clean-contaminated,
contaminated and dirty wounds)
II. for patients having clean operations in which a prosthetic device is placed
G. Principles of prophylactic antibiotics:
I. Prophylactic antibiotic therapy should be directed against the bacteria likely to
contaminate the wound.
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General surgery – 4th stage
II. The antibiotics usually should be given intravenously 30– 60 min before operation . it
should not be continued beyond the day of operation.
III. The value of antibiotic prophylaxis is low in non-prosthetic clean surgery, while they
are effective in reducing the risk of infection in clean-contaminated and
contaminated operations.
IV. Cephalosporins are the most commonly used antibiotics for prophylaxis because of
their broad antibacterial spectrum.
V. In long operations or when there is excessive blood loss, or when unexpected
contamination occurs, antibiotics may be repeated at 4-hourly intervals during the
surgery, because tissue antibiotic levels often fall faster than serum levels.
VI. Patients with known valvular disease of the heart (or with any implanted vascular or
orthopaedic prosthesis) should have prophylactic antibiotics during dental, urological
or open viscus surgery, to prevent bacterial colonisation of the valve or prosthesis
during the transient bacteraemia which can occur during such surgery
Opportunistic infection
An opportunistic infection is an infection caused by pathogens (bacteria, viruses, fungi,
or protozoa) that take advantage of an opportunity not normally available, such as a host with a
weakened immune system, an altered microbiota (such as a disrupted gut microbiota), or
breached integumentary barriers (due to injury or medical procedure like cannula, folley
catheter). Many of these pathogens do not cause disease in a healthy host that has a normal
immune system.
HOSPITAL-ACQUIRED (NOSOCOMIAL) INFECTIONS
The infection that is acquired in operative theatre and/or wards . The most important
and frequent mode of transmission of nosocomial infections is by direct contact. Others routes
of transmission are Droplet transmission, airborne, vehicle transmission(food, mediactions..)
and vector borne (such as mosquitoes, flies). The most common nosocomial infections are:
I. urinary tract infections are most common, followed by
II. wound infections
III. lower respiratory infections such as ventilator associated pneumonia
IV. bacteremia, and cutaneous infections
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General surgery – 4th stage
Surgical wound infections
The wounds have been classified into 4 categories according to the theoretical number of
bacteria that contaminate wounds:
Wound Class Definition Examples of Wound Usual
Typical Infection Organisms
Procedures Rate (%)
Clean Nontraumatic, elective surgery; Wide local 2 Staphylococcus
no entry of GI, biliary, excision of breast aureus
tracheobronchial, respiratory, or mass
GU tracts
Clean- Respiratory, genitourinary, GI Gastrectomy, <10 Related to the
contaminated tract entered but minimal hysterectomy viscus entered
contamination
Contaminated Open, fresh, traumatic wounds; Ruptured 20 Depends on
uncontrolled spillage from an appendix; underlying
unprepared hollow viscus; resection of disease
minor break in sterile technique unprepared bowel
Dirty Open, traumatic, dirty wounds; Intestinal fistula 28–70 Depends on
traumatic perforated viscus; pus resection underlying
in the operative field disease
