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1 SURGICAL INFECTIONS & ANTIBIOTICS 428 surgery team M K ALAM MS, FRCS Prof. & Consultant Surgeon College of Medicine & RCH Done by : 428 surgery team 2 OBJECTIVES 428 surgery team • Definitions. • Pathogenesis . • Clinical features . • Surgical microbiology. • Common infections. • Antibiotics use. 3 428 surgery team INFECTION Invasion of the body by pathogenic microorganisms and reaction of the host to organisms and their toxins ( the def. its 2 part :1- invase of organism 2- body respond to it ) 4 428 surgery team SURGICAL INFECTIONS Infections that require surgical intervention as a treatment [1] or develop as a result of surgical procedure [2]. Appendicitis : 1- comes? the infection – need treatment by surgery 2- surgery – complictaion 5 Surgical Infection 428 surgery team • A major challenge • Accounts for 1/3 of surgical patients • Morbidity increase • Mortality increase • Increased cost to healthcare 6 428 surgery team Factors contributing to infections • Microorganism related factors: -Adequate dose ( many organism ) -Virulence of microorganisms • Host related factors: -Suitable environment ( closed space ) ( make an env. For the body to accept the organism ) . -Susceptible host ( weak immunity ) 7 428 surgery team Pathogenicity of bacteria ( wt makes organism pathogen ?) -Exotoxins: specific effect for each bacteria type , soluble proteins, remote cytotoxic effect , released from intact bacteria e.g Cl.Tetani cause tetanus, Strep. Pyogenes cause infection having an acid -Endotoxins: part of gram-negative bacterial wall, released only after destruction of bacteria , lipopolysaccharides e.g., E coli Resist phagocytosis: Protective capsule Klebsiela and Strep. Pneumoniae -Explain: 1- toxin ----- EX. Secretions ---- END. Part of the organism which distorted it 2- resist phagocytosis 8 428 surgery team Host Resistance Intact skin / mucous membrane. (surgery/ trauma- causes breach) by breaking the skin during the surgery which is a defensive mechanism for the body . Immunity: like patient who treated by cortisone , they have weak immunity Cellular (phagocytes ) Antibodies 9 428 surgery team Classification of infection - Autoinfection(endogenous) :pathogen from within the patient - Community acquired : e.g. flu -nosocomial : from hospital environment -iatrogenic : secondary to theraby e.g. cathters - From carrier - Opportunistic infection 10 Clinical features 428 surgery team • Local- pain, heat, redness, swelling, some times loss of function. (apparent in superficial infections) • Systemic- ill , loss of appetite , fever, tachycardia, chills,rigors • Like appendicitis when patient come after 3 days with high fever this indicate as infection . 11 428 surgery team Principles of surgical treatment • • • • Debridement- necrotic, injured tissue [a] Drainage- abscess, infected fluid [b] Removal- infection source, foreign body[c] Supportive measures: to stop the spread of infection • a- immobilization “ bed rest “ • b- elevation “ swell less , rest elevation “ • c- antibiotics “ for appendicitis “ 12 STREPTOCOCCI 428 surgery team • Gram positive, manily aerobe/anaerobe • Flora of the mouth and pharynx oral cavity , bowel ) ( • Streptococcus pyogenes –( β hemolytic) 90% - 95% of infections e.g.,lymphangitis, cellulitis, rheumatic fever,pharyngitis • Strep. viridens- subacute bacterial endocarditis, urinary infection • Strep. Fecalis (bowel ) – urinary infection, pyogenic infection • Strep. pneumonae – pneumonia, meningitis not commonly seen 13 428 surgery team STAPHYLOCOCCI “ surgical wound infections “ • Inhabitants of skin, Gram positive anaerobes • Infection characterized by suppuration like HAI, immune weak • Staph.aureus- the most common , most pathogen SSI, nosocomial ,superficial infections • Staph. epidermidisopportunistic ( wound, endocarditis ) 14 428 surgery team CLOSTRIDIA • • • • • Gram positive, anaerobe Rod shaped microorganisms Live in bowel & soil Produce exotoxin for pathogenicity Important members: Cl. Perfringens, Cl. Septicum ( gas gangrene ) Cl. Tetani ( tetanus ) Cl. Difficile ( pseudomembranous colitis ) GRAM NEGATIVE ORGANISMS 15 428 surgery team ( Enterobactericiae ) Escherichia coli ( bowel infections ) Facultative anaerobe, Intestinal flora Produce exotoxin & endotoxin Endotoxin produce Gram-negative shock Wound infection, abdominal abscess, UTI, meningitis, endocarditis Treatment- ampicillin, cephalosporin, aminoglycoside 16 428 surgery team GRAM NEGATIVE ORGANISMS Pseudomonas most come in ICU patient • • • • • • aerobes, occurs on skin surface opportunistic pathogen may cause serious & lethal infection colonize ventilators, iv catheters, urinary catheters Wound infection, burn, septicemia Treatment: aminoglycosides, piperacillin, ceftazidime 17 GRAM NEGATVE ANAEROBES Bacteroides fragilis ( bowel surgery , investigation 428 surgery team by abscess with bad smell ) • • • • • • • Normal flora in oral cavity, colon Intra-abdominal & gynecologic infections ( 90% ) Foul smelling pus, gas in surrounding tissue, necrosis Spiking fever, jaundice, Leukocytosis No growth on standard culture Needs anaerobe culture media Treatment: Surgical drainage Antibiotics- clindamycin, metronidazole 18 428 surgery team TYPES OF SURGICAL INFECTION • • • • • A. Surgical Site Infection B. Soft Tissue Infection C. Body Cavity Infection D. Prosthetic Device related Infection E. Miscellaneous 19 Surgical site infection (SSI) 428 surgery team 38% of all surgical infections • Infection within 30 days of operation • Classification: • - Superficial: Superficial SSI–infection in subcutaneous plane (47%) - Deep: Subfascial SSI- muscle plane (23%) Organ/ space SSI- intra-abdominal, chest infections ,other spaces (30%) Staph. aureus- most common organism • E coli, Entercoccus ,other Entetobacteriaceae- deep infections • B fragilis – intrabd. abscess 20 428 surgery team Surgical site infection (SSI) • Risk factors: age, malnutrition, obesity, immunocompromised, poor surg. tech, prolonged surgery, preop. shaving and type of surgery. • Diagnosis: Sup.SSI- erythema, oedema, discharge and pain Deep infections- no local signs, fever, pain, hypotension. need investigations. • Treatment: surgical / radiological intervention. 21 428 surgery team 22 Prevention of SSI 428 surgery team • Pre-op: Treat pre-existing infection Improve general nutrition Shorter hospital stay Pre-op. shower Hair removal timing? Should if the surgery take long time , or the area need to shave. • Intraoperative: Antiseptic technique Surgical technique • Post-operative: Hand hygiene 23 STREPTOCOCCAL INFECTIONS 428 surgery team Erysipelas • • • • • • Superficial spreading cellulitis & lymphangitis Area of redness, sharply defined irregular border Follows minor skin injuries Strep pyogenes Common site: around nose extending to both cheeks Penicillin, Erythromycin 24 428 surgery team 25 428 surgery team SREPTOCOCCAL INFECTION Cellulitis • • • • • • Inflammation of skin & subcutaneous tissue Non-suppurative Strep. Pyogenes Common sites- limbs Affected area is red, hot & indurated Treatment : Rest, elevation of affected limb Penicillin, Erythromycin Fluocloxacillin ( if staph. suspected ) 26 428 surgery team 27 NECROTIZING FASCIITIS 428 surgery team • Necrosis of superficial fascia, overlying skin • Polymicrobial : Streptococci (90%), anaerobic Grampositive Cocci, aerobic Gram-negative Bacilli, and the Bacteroides spp. • Sites- abd.wall (Meleny’s), perineum (Fournier’s), limbs, • Usually follows abdominal surgery or trauma 28 NECROTIZING FASCIITIS 428 surgery team we have 2 do the investigation 2 differentiated from simple crllulitis • Diabetics more susceptible • Starts as cellulitis, edema, systemic toxicity • Appears less extensive than actual necrosis • Investigation: Aspiration, Gram’s stain, CT, MRI • Treatment: IV fluid, IV antibiotics (ampicillin, clindamycin l metronidazole, aminoglycosides ) Debridement , repeated dressings, skin grafting 29 428 surgery team 30 428 surgery team STAPHYLCOCCAL INFECTIONS • Abscess- localized a lot creamy pus collection Treatment- drainage, antibiotics • Furuncle- infection of hair follicle / sweat glands • Carbuncle- extension of furuncle into subcut. tissue common in diabetics common sites- back, back of neck Treatment: drainage, antibiotics, control diabetes 31 428 surgery team 32 428 surgery team GAS GANGRENE grame (+) anaerobe • Cl. Perfringens, Cl. Septicum • Exotoxins: lecithinase, collagenase, hyaluridase • Large wounds of muscle ( contaminated by soil, foreign body ) • Charcterized by progressive ,rapidly spreading edema • Rapid myonecrosis (Affect mainly muscle and cause muscle necrosis) , crepitus in subcutaneous tissue • Seropurulent discharge, foul smell, swollen • Toxemia, tachycardia, ill looking • X-ray: gas in muscle and under skin • Treatment : • - Penicillin, clindamycin, metronidazole -Wound exposure, debridement , drainage, amputation -Hyperbaric oxygen chamber 33 TETANUS gram + , not seen recently unless u didn’t get 428 surgery team the vaccine , or didn’t take the booster • • • • • • • • • Cl. Tetani, produce neurotoxin Penetrating wound ( rusty nail, thorn ) Usually wound healed when symptoms appear Incubation period: 7-10 days Trismus- first symptom, stiffness in neck & back muscle spasm Anxious look with mouth drawn up ( risus sardonicus) Respiration & swallowing progressively difficult Reflex convulsions along with tonic spasm Death by exhaustion, aspiration or asphyxiation 34 428 surgery team risus sardonicus • Contraction of jaws >> become closed.. While the lips >> open & tooth visible . 35 TETANUS 428 surgery team • Treatment: wound debridement, penicillin Muscle relaxants, ventilatory support Nutritional support • Prophylaxis: wound care, antibiotics Human tetanus immunglobulin (HTIG )in high risk ( un-immunized ) Commence active immunization ( T toxoid) Previously immunizedbooster >10 years needs a booster dose booster <10 years- no treatment in low risk wounds 36 428 surgery team PSEUDOMEMBRANOUS COLITIS • • • • gram + Cl. Difficile Overtakes normal flora in patients on antibiotics Watery diarrhea, abdominal pain, fever Sigmoidoscopy show: membrane of exudates (pseudomembranes) • Diagnosis :Stool- culture and toxin assay • Treatment : stop offending antibiotic oral vancomycin/ metronidazole rehydration, isolate patient 37 428 surgery team 38 Body Cavity Infection abdominal and 428 surgery team • Primary peritonitis: Spontaneous, weak immune . Children, Ascitic immuno Haematogenous/ lymphatic route Tt /Antibiotic • Secondary peritonitis: infection one of the organ in abdomen Inflam./ rupture of viscera Polymicrobial Investigations: blood, radiological Tt/ of original cause 39 428 surgery team 40 428 surgery team 41 428 surgery team Prosthetic Device Related Infection • • • • • Artificial valves and joints Peritoneal and haemodialysis catheters Vascular grafts patient may have hernia repair Staphylococcus aureus Antibiotics, washing of prosthesis or removal 42 428 surgery team Hospital Acquired Infection • Occurring within 48 h of hospital admission, three days of discharge or 30 days following an operation • 10% of patients admitted to hospitals • Spent 2.5-times longer in hospital - UK • Highest prevalence in ICU• Enterococcus, Pseudomonas spp.,E coli(exo & endo toxin), Staph. aureus. • Sites: Urinary, surg. Wounds, resp., skin, blood, GIT Wt is the most common site in HAI ? 43 428 surgery team ANTIBIOTICS Chemotherapeutic agents that act on organisms • Bacteriocidal: Penicillin, Cephalosporin, Vancomycin Aminoglycosides • refers to the treatment of a bacterium such that the organism is killed • Bacteriostatic: Erythromycin, Clindamycin, Tetracycline • refers to a treatment that restricts the ability of the bacterium to grow 44 ANTIBIOTICS surgery team THE DOC SAID READ428IT • Penicillins- Penicillin G, Piperacillin • Penicillins with β-lactamase inhibitors- Tazocin • Cephalosporins (I, II, III)- Cephalexin, Cefuroxime, Ceftriaxone • Carbapenems- Imipenem, Meropenem • Aminoglycosides- Gentamycin, Amikacin • Fluoroquinolones- Ciprofloxacin • Glycopeptides- Vancomycin • Macrolides- Erythromycin, Clarithromycin • Tetracyclines- Minocycline, Doxycycline 45 428 surgery team ROLE OF ANTIBIOTICS “ given a scenario and ask if its therapeutic or prevention” • Therapeutic: To treat existing infection • Prophylactic ( PREVENTION ) : To reduce the risk of wound infection 46 ANTIBIOTIC THERAPY 428 surgery team • Pseudomembranous colitis- oral vancomycin/ metronidazole • Biliary-tract infection- cephalosporin or gentamycin • Peritonitis- cephalosporin/ gentamycin + metronidazole/ clindamycin • Septicemia- aminoglycoside + ceftazidime, Tazocin or imipenem, ( may add metronidazole ) • Septicemia due to vascular catheter- Flucloxacillin/ vancomycin • Cellulitis- penicillin, erythromycin ( flucloxacillin if Staphylococcus infection. Suspected ) or Cefuroxime 47 ANTIBIOTIC PROPHYLAXIS 428 surgery team BASED ON SURGICAL WOUND CLASSIFICATION • Clean wound no organism present - e.g., thyroid surgery ( 2% ) , repair of hernia , removing a laparotomy(NOT in GIT ,Resp. Sys. , or GU sys). • Typically an elective surgery in a non-contaminated, non-traumatic and non-inflamed surgical site • Clean-contaminated- minimal contamination e.g., biliary, urinary, GI tract surgery ( 5-10% ) • Here surgery involves the respiratory, GI or genitourinary system, ie often a hollow organ • Contaminated-gross contamination e.g., during bowel surgery- (up to 20% ) • Similar surgeries, but with leakage or a major break in aseptic technique • Dirty- surgery through established infection peritonitis ( up to 50% ) NOT prophylaxis BUT antibiotic • A hollow organ is ruptured e.g., 48 428 surgery team ANTIBIOTIC PROPHYLAXIS (IMP ) * Prophylaxis in clean-contaminated/ high risk clean wounds * Antibiotic is given just before patient sent for surgery *Duration of antibiotic is controversial ( one dose- 24 hour regimen ) *Hernia- one dose preoperatively, can be pre and post operative or for 24hrs or even days. 49 428 surgery team