Surgical Infections

MS-3 Surgery Clerkship Lecture

Natalia Hannan M.D.
07/05/11
Ignaz Semmelweis
1847
Realized that washing
hand with a chlorinated
lime solution decreased
incidence of newborn
death from puerperal
fever.
Joseph Lister
1883-1897
British surgeon
Used Carbolic Acid
(Phenol) to clean
hands, instruments
and wipe on surgical
wounds drastically
decreased infections.
Overview
Recognizing Infection
Soft Tissue Infections
Post-operative Infections
Surgical Site Infection
Hospital Acquired Infections
Antibiotic Prophylaxis
Blood Born Pathogens
Infection
Infection is defined by:

1. Microorganisms in host tissue or
the bloodstream
2. Inflammatory response to their
presence.

Inflammatory Response
Localized:
Rubor, Calor, Dolor, Tumor, and functio
laesa (loss of function)

Systemic:
Systemic Inflammatory Response Syndrome
(SIRS)
S.I.R.S.
Any Two of the Following Criteria

1. Temperature: < 36.0, >38.0
2. Heart Rate : >90
3. Respiratory Rate: >20
4. WBC: <4,000, >12,000
Sepsis
Definition: SIRS plus evidence of local
or systemic infection.
Septic Shock
Definition: Sepsis plus end organ
hypoprofusion. Mortality of up to
40%
Soft Tissue Infections:
1. Cellulitis
2. Abscess
3. Necrotizing Infections
Cellulitis

Cellulitis
Definition: Diffuse infection with severe
inflammation of dermal and
subcutaneous layers of the skin

Diagnosis: Pain, Warmth, Hyperesthesia

Treatment: Antibiotics.

Common Pathogens: Skin Flora
(Streptococcus/Staphylococcus)
Abscess

Abscess
Definition: Infectious accumulation of
purulent material (Neutrophils) in a
closed cavity

Diagnosis: Fluctuant: Moveable and
compressible

Treatment: Drainage

Necrotizing Soft Tissue
Infection
Necrotizing Soft Tissue
Infection
Definition: Deep infection of skin and soft tissue
that may spread rapidly along facial planes.

Diagnosis: Purely Clinical, dishwater discharge,
gray tissue, pain out of proportion to
examination, bulla, and dark, golden
discoloration.

Treatment: True Surgical Emergency, Antibiotics
Necrotizing Soft Tissue
Infection
Common Pathogens
Clostridium
Group A streptococcus
Polymicrobial
Toxic Shock Syndrome
Streptococcus
Staphylococcus
Post-Operative Infections
Fever After Surgery
The Five Ws
Wind: Atelectisis
Water: UTI
Walking: DVT
Wonder Drug: Medication Induced
Wound: Surgical Site Infection
Surgical Site Infections
3rd most common hospital infection
Incisional
Superficial
Deep
Organ Space
Generalized (peritonitis)
Abscess

Types of Surgery
Clean Hernia repair
breast biopsy
1.5%
Clean-
Contaminated
Cholecystectomy
planned bowel resection
2-5%
Contaminated Non-preped bowel
resection
5-30%
Dirty/infected perforation, abscess 5-30%
Host Risk Factors
Diabetes mellitus
Hypoxemia
Hypothermia
Leukopenia
Nicotine (tobacco smoking)
Immunosuppression
Malnutrition
Poor skin hygiene
Perioperative Risk
Factors
Operative site shaving
Breaks in operative sterile technique
Improper antimicrobial prophylaxis
Prolonged hypotension
Contaminated operating room
Poor wound care postoperatively
Hyperglycemia
Wound closure technique
Treatment
Incisional: open surgical wound,
antibiotics for cellulitis or sepsis

Deep/Organ space: Source control,
antibiotics for sepsis
Operative Antibiotic
Prophylaxis
Decreases bacterial counts at surgical site
Given within 30 minutes prior to starting
surgery
Vancomycin 1-2 hours prior to surgery
Redose for longer surgery
Do not continue beyond 24 hours


Other Hospital Acquired
Infections
1. Urinary Tract Infection
2. Indwelling Catheter Infection
3. Pneumonia
Use/Choice of Antibiotics
Use only when indicated
Start with broad spectrum antibiotics
designed to cover likely pathogens
Take cultures when possible
Deescalate spectrum once pathogen is
know
Have a plan for duration
Occupational Blood
Bourne Virus Infections
HBV HCV HIV
Risk from
Needle stick
30% 2% 0.3%
Chemoprophylaxis Yes No Yes
Vaccine Yes No No