Surgical Infections

Guo Xueli ( 郭学利 )

Dept. General Surgery, First Affiliated
Hospital
Surgical infections and choice of antibiotics
Many operations were developed
---after anesthesia during
the 2nd half of the 19th century
Advances were few
--- the high rate of infections
the high mortality that followed
infections
The antiseptic principle---Lister
The concepts of asepsis and antisepsis
---Louis Pasteur el al
revolutionized the practice of surgery
Application of antiseptic practices
---infection rate for elective operations to
drop from 90% to 10%
Around the turn of the century---
the practice of wearing gloves during operations
These basic principles of controlling infections---
Changing surgical therapy
Despite these gains
#the many procedures performed ---numerous
postoperative surgical site infections
#infections--- increased morbidity and mortality
#the cost of the care of postoperative wound
infections---enormous
Antibiotic therapy---the serious surgical
infections would be eliminated
Unfortunately
#postoperative wound and hospital-acquired
infections---continued
#prevention and control of surgical
infections---more difficult
New serious infections related to a complex
combination of factors
#more complicated and longer operations
#accompanying chronic or debilitating diseases
#new surgical procedures
---implants of foreign materials
---organ transplants requiring the use of
immunosuppressive agent
---use of diagnostic and treatment modalities that
caused bacterial exposures or the suppression
of normal host resistance
YOU, a modern surgeon, cannot escape
the responsibility to deal with infections!

To realize the knowledges

#microbiology, immunology, pharmacology
#how the body defends itself against infections
#therapeutic principle to control of infections
Causes of wound infection

#Bacterial factors
#Local wound factors
#Patient factors
All clean operative wound
---small numbers of bacteria
Only a small number---infections
#Microbial numbers and virulence
#Host defense
Bacterial factors
The development of infection
#Prerequisite---the deposition and growth of
bacteria
#the kind and number
#the toxins produced by the organism
#the organism’s ability to resist phagocytosis
and intracellular destruction
Surface components---contribute to their
pathogenicity by inhibiting phagocytosis
Gram-negative bacteria---endotoxin or
lipopolysaccharide that are toxic
Clostridia and streptococci---exotoxins that
permit bacteria to establish invasive
infections
Most wounds ---one or more types of organisms
can be culture
Clean wounds---skin bacteria, staphlococcus
epidermidis or diphtheroid
Traumatic wounds---staphlococcus aureus and
streptococcus pyogens
Devitalized tissues and foreign materials
---far fewer organisms cause infection in
wounds than normal tissues
Overt infection is unusual
unless cardinal surgical principles have been
violated or exceptionally large numbers of
organisms have been introduced into the wound
---the normal defense mechanism are great
importance in preventing infections
Local wound factors
Inhibition of local defense mechanisms for
clearing bacteria---the most important cause
of wound infection
anything---that interferes with the ability of
phagocytic cell to contact directly and kill
bacteria---infection
The use of foreign bodies---sutures and drains
Lack of accurate approximation of tissues
Strangulation of tissue with suture that are tight
The presence of any dead tissue, hematomas, or
seromas
If you have good surgical technique,
you can minimize the most of these factors!
Patient factors
Wound infections are more common in the
very young and the very old
---immature or senescent resistance mechanisms
#anything that reduces blood flow to the surgical
incision---vascular occlusive states, hypovolemic
shock, or with use of vasopressors or
vasoconstrictor
#local decrease in tissue oxygen tension
#condition that reduce vascular reactivity as in uremia, old
age, or the use of high doses of corticosteroids and other
drugs cause an increased susceptibility to infection
#cancer and trauma---complement activation which influence
both T-cell and phagocytic cell function
Prevention of wound infection
Preventing infectious complications is far more
practical than treating them
#strict adherence to the principles of wound care
#application of knowledge concerning the
pathogenesis of wound infections
---can preventing the vast majority of infectious
complications
Most important ---constant vigilance of the
operating team, including the surgeon
Avoidance of bacterial contamination
Environmental Factors
Engineering and architectural advances
---limit airborne contamination
the two greatest sources of significant microbial
contamination
---exogenous contract from break in technique
by operative team
---exogenous contract from the patient’s skin
and various bacteria containing tracts
#The use of ultraviolet light
#Laminar flow ventilation systems
#Important---limiting traffic in and out
providing positive pressure
limiting activity and talking
#Increasing numbers of people
---increase opportunity for breaks in sterile
technique and dispersion of airborne bacteria
#Air handling, sterilization techniques must be
strictly monitored
Preoperative Preparation of the Patient
#Take a preoperative shower the night before
operation using an antibacterial soap
#All cutaneous infections should be
controlled or cleared
Presence of a distant-site infection at the
time of an elective clean operation doubles
the postoperative infections rate
Hair Removal
Shaving hair increases the infection rate
about 100% compared with removing the
hair by clippers at the time of the procedure
or not removing it at all
# Extensive removal of hair---no
#Any that is done should be performed by
electric clippers with disposable heads in
the operating room at the time of the
procedure
Skin Preparation
The skin---an important source of organisms
contaminating surgical wounds
Two methods
---to scrub the entire operative area of the
patient for 5 to7 minutes with a germicidal
detergent solution, then paint the region with
an antimicrobial solution of either tincture of
iodine, povidone-iodine, or chlorhexidine
---to use an antimicrobial incise drape
The operating room team and discipline
the operating room team---one of the most important
sources of organisms in clean cases
---wear clean scrub suits, caps, masks
---the hands and forearms should be cleansed and
scrubbed thoroughly with an antimicrobial soap for 3-5
minutes
---careful gowning and gloving techniques, special
attention should be paid to avoiding contamination
when the patient is draped
Another frequent source of contamination---the use of
sterile light handles, which become contaminated by the
headgear of the operating team
#the gloves punctured or torn should be changed
immediately
The safest gloving practice---to wear two pairs of
gloves
#the gowns worn---an important source of
contamination
The contact areas (i.e., sleeves and front of the
gown) should be impervious to bacteria and fluids
whether the gowns are disposable or reused
Endogenous contamination
Another very important but not always heeded
source of contamination--- Endogenous
contamination at the time of transection of the
gastrointestinal, respiration, or genitourinary
tract
Bacterial contamination occurs to varying
degrees any time a hollow viscus is transected
#The operative area should be carefully isolated
from the remainder of the operative field before
a hollow viscus is entered
#A completely different set of instruments should
be used for that portion of the operation until
the hollow viscus is closed
#All instruments, towels, and sponges that may
have come into contact with the contaminated
area must be removed from the operative field
#The gowns and gloves of the operative team
should be changed
The importance of surgical technique
Gentle care of the tissues to minimize local damage---
one of the most important ways to prevent infection
---all devitalized tissues and foreign bodies should be
removed from traumatic wounds
The wound not be closed---complete debridement is
not possible
---try to avoid the introduction of new foreign bodies
(prostheses, grafts, and suture materials)
The presence of hematomas, seromas, or dead
spaces factors bacterial localization and growth
and prevents the delivery of phagocytic cells to
such foci
The best way to prevents the fluid collection and
infection ---to provide a system of closed suction
drainage
Systemic factors
Host resistance is abnormal in a variety of systemic
conditions and diseases, including leukemia,
diabetes mellitus, uremia, prematurity, burn or
traumatic injury, advanced malignancy, old age,
obesity, malnutrition , and several diseases of
inherited immunodeficiency.
---extraordinary precautions should be taken, including
correction or control of the underlying defect
whenever possible
Malnutrition---significantly impair host
defense mechanisms
Hypermetabolism, this type of insidious
malnutrition is probably the most important
cause of acquired immunologic deficiencies
---to correct any underlying malnutrition
before surgical therapy
Alimentation by the oral route is preferable
Social considerations
#Infection rates---determined at 30days postoperatively
rather than at discharge because more than one half of
the infections occur after discharge
#Each infection that is noted should be
---discussed in the surgical complications meeting
---categorized as apparently avoidable or apparently
unavoidable
The goal of surveillance and quality assurance should
be to have no avoidable infections
Immunotherapy
Active and passive immunotherapy to prevent
surgical infection has merit in only a few
specific instance
*outstanding success in preventing tetanus
* in preventing rabies
* the use of pooled human gammaglobulin ---
agammaglobulinemia or a
dysgammaglobulinemia
Reducing the bacterial load
by prophylactic chemotherapy
The administration of therapeutic doses of
antimicrobial agents can prevent infection in
wound contaminated by bacteria highly sensitive
to the agents
To use prophylactic antibiotic therapy---must be
based on the weight of evidence for possible
benefit against the weight of evidence for
possible adverse effects
#indiscriminate or blind use of antibiotics---lead
to emergence of antibiotic-resistant strains of
organisms or serious hypersensitivity reaction
#prolonged use of prophylactic antibiotics---
mask the signs of established infections,
making diagnosis more difficult
# prophylactic antibiotic therapy
---no substitute for careful surgical technique
---be used effectively only adjuvants to
adequate surgery
# prophylactic antibiotic therapy
---in these situations which involve a brief
period of contamination by organisms that can
predicted with reasonable accuracy
Prophylactic antibiotic therapy in the following
circumstances:
1.High-risk gastroduodenal procedures
2.High-risk biliary procedures
3.Resection and anastomosis of colon or small
intestine
4.Cadiac procedures through a median sternotomy
5.Vascular surgery of the lower extremities or
abdominal aorta
6.Amputation of an extremity with impaired blood
supply, particularly in the presence of a current
or recent ischemic ulcer
7.Vaginal or abdominal hysterectomy
8.Primary cesarean section
9.Operations entering the oral pharyngeal cavity
in continuity with neck dissections
10.Craniotomy
14.Injuries prone to clostridial infection because
of extensive devitalization of muscle, heavy
contamination, and/or impairment of blood
supply
15.Presence of pre-existing valvular heart
damage, to prevent the development of
bacterial endocarditis
11.The implantation of any permanent prosthetic
material
12.Any wound with known gross bacterial
contamination
13.Accidental wounds with heavy contamination
and tissue damage.
#prophylactic antibiotic therapy is clearly more
effective when begun preoperatively and
continued the intraoperative period
#the use of topical antibiotics often effectively
diminishes the incidence of infection in
contaminated wounds
# prophylactic antibiotic therapy is generally
ineffective in clinical situations in which
continuing contamination is likely to occur