Acute non-specific surgical infections:
Contamination; it means the mere presence of micro-
organisms in a wound.
Infection; means invasion of tissues by micro-organisms and
produce ill-effects.
Bacteremia; means the a symptomatic presence of bacteria, not
multiplying in the blood. Its harmless. It usually follows dental
work and instrumentation of the urinary tract especially in the
presence of infection. It is hazards in patients with damaged
heart valves or with prosthetic valves because micro-organisms
may settle on these valves or prostheses causing severe
damage. It is also dangerous in in patients with
immunosuppression. Antibiotic prophylaxis is essential in such
cases. Gram +ve bacteremia is less significant than Gram-ve.
Septicemia; means the presence of multiplying
organisms in the blood stream plus leukocytosis.
Sepsis; it is the clinical reflection of bacterial
infection.it denotes significant infection in which
bacteria, bacterial toxins or inflammatory mediators
escape the control of the immune system, enter the
circulation and produce a systemic response including
chills, fever and sometimes pulmonary failure or
shock.
Pathogenesis;
The development of infection depends on interaction
between an infectious agent and a susceptible host.
in addition to the presence of a closed un-perfused
space.
1) The infectious agent; either endogenous or
exogenous agents.
Endogenous agents; there are many normal non-
pathogenic microflora in different parts of the body.
Infection occurs when barriers that separate them
from sterile areas of the body are disrupted. ex; skin
posses staphylococci and streptococci, GIT has
resident flora in oropharynx, colo-rectum and distal
ileum.
Exogenous agents;
As hospital acquired infections, other patients, staff members and
faults in sterilization systems.
2) Host reaction;
It depends on host’s immune mechanisms
Non-specific immunity; phagocytic leucocytes by chemotaxis by
aid of a complement migrate to the site of infection, adhere to the
organisms and engulf it then kill it by lysosomes or by oxidative
killing.
Corticosteroids and malnutrition reduce the number of leucocytes
that arrive the contaminated site.
Uncontrolled diabetics, the migration, adherence and killing by
bacteria are impaired improved by control of diabetes.
Specific immunity; developed by production of specific antibodies
on prior exposure to antigen with subsequent activation of T and
B lymphocytes. Immunosuppression due to AIDS,
immunosuppression therapy results in increased infection.
3) The closed space;
Most surgical infections start in a susceptible poorly vascularized
area such as a wound or a natural space. Poor perfusion, hypoxia,
hypercapnia and acidosis all predispose to infection. Natural spaces
with narrow outlets such as the gall bladder, appendix and
diverticula are especially prone to become obstructed and then
infected.
Bacteriology;
1) Staphylococci; Gram-positive cocci live in skin appendages
as sweat and sebaceous glands and in nostrils.
It produces toxins as coagulase, leucocidin, and alpha
trypsin. Some strains produce penicillinase making them
resist penicillin. The most resistant strain called MRSA
(methicillin resistant Staph aureus).
It produces boils, carbuncles, paronychia, osteomyelitis,
breast abscess and pneumonia.
2) Streptococci; Gram positive cocci grow in chains. There
are hemolytic and non-hemolytic. The hemolytic type
present in nasopharynx transmitted by droplet infection and
in spreading infections like cellulitis, erysipelas and
lymphangitis. The non-hemolytic is less virulent and present
in mouth and bowel causing dental sepsis.
Aerobic Gram-ve bacilli;
Escherichia coli ( E-coli); present in the intestinal tract. They
are non-pathogenic under normal conditions but they are the
cause of suppurative intra-abdominal infections and urinary
tract infection.
Klebsiella; encapsulated Gram negative bacilli found in
respiratory tract causing fatal pneumonia in debilitated cases.
Pseudomonas aeruginosa; present in feces acts usually as a
second invader in open wounds and burns and recognized by
its blue-green colour and characteristic odour of its pus which
is difficult to irradicate.
Proteus; common cause for urinary tract infection and in mixed
infection.
4) Anaerobic bacteria; peptostreptococci and gram negative
bacilli (bacteroids) found in skin and mucus membrane. When
epithelial barrier disrupted become pathogenic and produce
abscess and septicemia. Its abscess is gas-forming, tissue
necrosis and foul smelling discharge following colon,oral and
Complications;
1) Spread of infection;
a) direct;
* Necrotizing infections; spread along anatomical paths as
necrotizing fasciitis spreads along poorly perfused fascial and
subcutaneous planes while its toxins cause thrombosis of large
vessels ahead of the necrotic area resulting in more ischemic
vulnerable tissue.
* abscesses; may enlarge and destroy surrounding tissues.
* phlegmon; contain little pus and much edema.
b) Lymphatic spread;
Streptococci and occasionally staphylococci produce
lymphangitis.
c) Blood spread; result in distant abscesses as pyaemic liver
abscess in following inflammatory bowel disease.
2) Fistula and sinus; perianal fistula
3) Necrosis and gangrene; s
4) Suppressed wound healing; due to stimulation of
collagenase production by bacteria.
5) Immunosuppression; due to toxins from uncontrolled
infection with superinfection.
6) Systemic inflammatory response syndrome (SIRS) and
multiple organ failure (MOF);
it’s the most serious complication of acute infection and is
caused by major sepsis. It results from release of
endotoxins by gram negative organisms leading to
septicemia. Prognosis of septicemia is related to the age
and general health of the patient and the number of
affected organs. If one organ is affected (lung or kidney)
70% of patients recover, if two organs are involved
recovery is 50%, if more than two prognosis is worse.
Diagnosis;
1) Clinical examination;
The inflamed area is painful, red, hot, tender with loss of
function. The draining lymph nodes may be enlarged painful and
tender. Constitutional manifestations as fever, headache, malaise
and tachycardia. Dyspnoea and rigors may occur in severe cases
indicating septicemia or pyaemia.
2) Laboratory studies;
Mild to moderate leukocytosis with prevalence of immature
granulocytes ( shift to the left). In overwhelming sepsis, there may
be leucopenia, DIC, impaired hepatic, renal and respiratory
functions.
Bacteriological examination of the discharge and culture
sensitivity tests may be done after 3 day off of antibiotics in
serious infections particularly blood cultures. Three blood
samples are taken over 24 hours period and used for aerobic and
anaerobic cultures.
3) Imaging studies;
*plain radiographs;
Pulmonary infections
Subphrenic infection (elevated copula of diaphragm)
Psoas abscess ( obliterated psoas shadow)
Osteomyelitis
* Ultrasound, CT, radionuclide scans are very helpful in localizing
deep seated infections.
Principles of treatment;
1) Incision and drainage; once pus is formed it should
be drained.
2) Excision; some surgical infections may be excised as
infected appendix or amputation of a limb due to gas
gangrene .
3) Antibiotics; simple surgical infections that respond
to incision and drainage don’t require antibiotics but
infections likely to spread or persist require antibiotic
preferably on basis of culture sensitivity.
4) General supportive measures; predisposing factors
should be corrected to help the body combat infection
as control diabetes, nutritional support.
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