Surgical Infections

~group A, surgery~
TYPES
• Superficial
• Deep
• Organ/space
Soft tissue/wound

• Most common surgical patient nosocomial

infection
• 2/3 involved surgical incision, 1/3 deep
structures accessed by incision
• Deaths in patients with nosocomial infections—
77% related to infection.
Risk factors for SSI
• Diabetes
• Nicotine
• Steroids
• Malnutrition
• Length of preoperative hospitalization
• Nares colonization Staph Aureus
• Perioperative transfusion
PREOP PREPARATION OF PATIENT

• Scrub
• Skin prep
▫ Iodophors, chlorahexadine,betadine
• Hair removal(shaving off for surgical purpose)
• Antiseptic showering
▫ Reduce skin flora only
ANTIMICROBIAL PROPHYLAXIS
• Clean/contaminated procedures
▫ Vascular cases
▫ Cardiac cases
▫ Orthopedic prosthetic cases
• Second generation cephalosporin for distal
intestinal tract
Necrotizing Soft Tissue Infection
• Debridement/Resuscitation
• Antibiotics
• Nutrition
▫ 1.5 to 2 times basal requirements
• Treatment delays are predictive of adverse
outcome
Necrotizing Soft Tissue
Infection(NSTI)
• Mortality rate as high as 40%
• Impaired immune system
• Compromised tissue blood supply , anticipate
TISSUE ISCHEMIA…GANGRENE
• Microorganisms (Polymicrobial)
• “skin poppin’” or “muscling”
• 1/3 diabetics involved
• 90% with comorbid conditions
Antibiotic therapy for NSTI
• Penicillin and aminoglycoside
• Clindamycin or metronidazole
• +/- Vancomycin
• Alternative: unasyn/zosyn
Hydradenitis suppurativa
• Infection of apocrine sweat glands
• axilla, groin, perineum, any skin fold
• Single abscess treated by I&D
• Doxycycline 100mg BID
• Excision with STSG (15%)
50 y/o diabetic with 2 & 3 degree
burns
• Develops full thickness necrosis of second
degree areas a few days later
• Third degree burn eschar unexpectedly
separated, revealing hemorrhagic discoloration
of the sub eschar fat.
Burn Infections
• Necrotic tissue readily colonized
• High bacteria counts are NOT a reliable
indication of an infected burn
• Histological examination to determine
invasiveness
• TREATMENT: debridement and antibiotics
50 y/o diabetic BELOW KNEE
AMPUTATION
• presents with rust colored fluid draining from
stump. Extremity is edematous and has some
associated erythema.
Gas gangrene
• Beta hemolytic strept
• Clostridium perfringes (gram pos rods)rare
• 50% polymicrobial
• Rapid lyses of tissues w/ relatively little response
from host
• Endotoxin release by microorganisms.
Gas gangrene
• Treatment:Aggressive debridement & antibiotics
• Repeat antibiotics if wound healing not
satisfactory
Catheter Sepsis
• 80% of cases, colonized catheters had been
inserted by inexperienced and experienced
residents

• Key is to identify infection before sepsis develops

• Stapylococcus epidermis, S. Aureus, yeast

Gram-Negative Sepsis
• E.coli, pseudomonas, klebsiella, Enterobacter
• >30% mortality
• Hypotension, hypoxia, acidosis, compliment and
coagulation cascade activation
• Lipopolysaccharide (LPS)/ endotoxin
Gram-Negative Sepsis
• 6ml/kg, plateau <30, good oxygen delivery
• Resuscitation
• SPO2
• Daily breathing trials(spirometry, chest physio)
• Sedation protocol
• DVT prophylaxis
A LITTLE BIT ON ANTIBIOTICS…
Inhibits cell wall synthesis
• A. Amphotericin B
• B. Penicillin
• C. Cephalosporins
• D. Aminoglycosides
• E. Quinolones
Inhibits cell wall synthesis
• A. Amphotericin B
• B. Penicillin
• C. Cephalosporins
• D. Aminoglycosides
• E. Quinolones
Impairment of bacterial DNA synthesis
• A. Amphotericin B
• B. Penicillin
• C. Cephalosporins
• D. Aminoglycosides
• E. Quinolones
Impairment of bacterial DNA synthesis
• A. Amphotericin B
• B. Penicillin
• C. Cephalosporins
• D. Aminoglycosides
• E. Quinolones
Disruption of membrane barrier
function
• A. Amphotericin B
• B. Penicillin
• C. Cephalosporins
• D. Aminoglycosides
• E. Quinolones
Disruption of membrane barrier
function
• A. Amphotericin B
• B. Penicillin
• C. Cephalosporins
• D. Aminoglycosides
• E. Quinolones
Disruption of ribosomal protein
synthesis
• A. Amphotericin B
• B. Penicillin
• C. Cephalosporins
• D. Aminoglycosides
• E. Quinolones
Disruption of ribosomal protein
synthesis
• A. Amphotericin B
• B. Penicillin
• C. Cephalosporins
• D. Aminoglycosides
• E. Quinolones