1. Surgical Infections
MS-3 Surgery Clerkship Lecture
Natalia Hannan M.D.
07/05/11

2. Ignaz Semmelweis
1847
Realized that washing
hand with a chlorinated
lime solution decreased
incidence of newborn
death from “puerperal
fever’.

3. Joseph Lister
• 1883-1897
• British surgeon
• Used Carbolic Acid
(Phenol) to clean
hands, instruments
and wipe on surgical
wounds drastically
decreased infections.

4. Overview
• Recognizing Infection
• Soft Tissue Infections
• Post-operative Infections
– Surgical Site Infection
– Hospital Acquired Infections
• Antibiotic Prophylaxis
• Blood Born Pathogens

5. Infection
Infection is defined by:
1. Microorganisms in host tissue or
the bloodstream
2. Inflammatory response to their
presence.

7. Inflammatory Response
Localized:
– Rubor, Calor, Dolor, Tumor, and functio
laesa (loss of function)
Systemic:
– Systemic Inflammatory Response Syndrome
(SIRS)

8. 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

9. Sepsis
Definition: SIRS plus evidence of local
or systemic infection.
Septic Shock
Definition: Sepsis plus end organ
hypoprofusion. Mortality of up to
40%

10. Soft Tissue Infections:
1. Cellulitis
2. Abscess
3. Necrotizing Infections

11. Cellulitis

12. 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)

13. Abscess

14. Abscess
Definition: Infectious accumulation of
purulent material (Neutrophils) in a
closed cavity
Diagnosis: Fluctuant: Moveable and
compressible
Treatment: Drainage

15. Necrotizing Soft Tissue
Infection

16. 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

17. Necrotizing Soft Tissue
Infection
• Common Pathogens
– Clostridium
– Group A streptococcus
– Polymicrobial
• Toxic Shock Syndrome
– Streptococcus
– Staphylococcus

18. Post-Operative Infections
• Fever After Surgery
• The “Five W’s”
– Wind: Atelectisis
– Water: UTI
– Walking: DVT
– Wonder Drug: Medication Induced
– Wound: Surgical Site Infection

19. Surgical Site Infections
• 3rd most common hospital infection
• Incisional
– Superficial
– Deep
• Organ Space
– Generalized (peritonitis)
– Abscess

21. 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%

22. Host Risk Factors
• Diabetes mellitus
• Hypoxemia
• Hypothermia
• Leukopenia
• Nicotine (tobacco smoking)
• Immunosuppression
• Malnutrition
• Poor skin hygiene

23. 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

24. Treatment
• Incisional: open surgical
wound, antibiotics for cellulitis or
sepsis
• Deep/Organ space: Source
control, antibiotics for sepsis

25. 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

27. Other Hospital Acquired
Infections
1. Urinary Tract Infection
2. Indwelling Catheter Infection
3. Pneumonia

28. 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

29. Occupational Blood
Bourne Virus Infections
HBV HCV HIV
Risk from
Needle stick
30% 2% 0.3%
Chemoprophylaxis Yes No Yes
Vaccine Yes No No