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Dr.T.Rudra Prasad Reddy M.S.

Normal defense against infection


1)Bacteria are prevented from causing infection to

tissues by intact skin. 2) Other protective barriers A)chemicallow gastric PH B)HumoralAntidodies, compliment and opsonins. C)cellular Phagocytic cells,Macrophages,polymorpho nuclear cells and lymphocytes.

Causes for reduced resistance to infection.


1)Metabolic

Malnutrition,Diabetes,ureamia,jaundice. (Host resistance is weakened) 2)Disseminated diseasesCancer,AIDS. 3)IatrogenicRadiotherapy,chemotherapy,steriods.

Opportunistic infections
When enteral feeding is suspended in post operative

period bacteria especially Gram negative bacilli translocated to mesenteric nodes. -- the endotoxins(lipo poly sacharoids from cell wall)that they release further increase susceptibility to infection. -- under these conditions bacteria that are not normaly pathogenic may start behaving as pathogens .This is known as OPPOURTUNISTIC INFECTIONS.

Risk factors for increased risk of wound infection.


1)Malnutrition wt loss, obesity.
2)Metabolic diseases-DM,ureamia,jaundice. 3)Immunosuppression

cancer,AIDS,chemothearapy,radiotherapy,st eroids. 4)colonisation and translocation of GIT. 5)poor perfusion systemic shock, local ischemia. (cont)

6)Foreign body material suture material, drains


7)poor surgical technique dead space, hematoma

Factors that determine whether wound will get infected


1)virulence and dose of infective agent.
2)Vascularity and health of the tissue

involved.(Devitalized tissue,execessive dead space or hematoma increase the chance of bacteria gaining a foothold in tissue.) 3)presence of foreign body like sutures ,drains. 4)presence of antibiotic during decisive period.

The acute inflammatory humoral and cellular

response take up to 4 hours to mobilize body response in its deffense. This is called DECISIVE PERIOD .It is the time when the invading bacteria have head start in established in the tissues. Prophylactic antibiotic should be given to cover this period

Important Definitions
Colonization Bacteria present in a wound with no signs or symptoms of systemic inflammation Usually less than 105 cfu/mL Contamination Transient exposure of a wound to bacteria Varying concentrations of bacteria possible Time of exposure suggested to be < 6 hours SSI prophylaxis best strategy

Contd;
Infection Systemic and local signs of inflammation Bacterial counts 105 cfu/mL Purulent versus nonpurulent
Surgical wound infection is SSI

Local and systemic manifestations of infection.


Infection of the wound is defined as the invasion of

organisms through tissues following breakdown of local and systemic host deffenses. Infected surgical wound is known as superficial surgical site infection (SSSI) Minor wound infectionmay discharge pus or infected serous fluid but not associated with execssive discomfort ,systemic signs or delay in dischage of pt . (contd)

Contd)
--Major wound

infection-- is a wound that either discharges significant quantity of pus spontaneously or need a secondary procedure to drain it. Patient may have systemic signs like such as tachycardia ,pyrexia, raised WBC count. Planed discharge from ward may be delayed.

SEPSIS
Sepsis is the systemic manifestations of infection. The

signs and symptoms of which may also may be caused by multiple trauma ,burns or pancreatitis. This will produce a condition called SYSTEMIC INFLAMATORY RESPONSE SYNDROME.(SIRS) Features of SIRSany two of the following features 1)Hyperthermia 38 C or Hypothermia<36C 2)Tachycardia >90/mt(with out use of blocker) 3)Tachyapnoea >20/mt 4)WBC count >12,000/cmm or<4000/cmm.

Multi organ dysfunction syndrome (MODS)


MODS is the effect that the infection has on whole

body. MODS is mediated by 1)release of cytokines such as interleukins (IL). 2)Tumor necrosis factor (TNF). 3)Other substances from poly morpho nuclear cells and phagocytes, Multi System organ failure (MSOF) is the end stage of MODS (Multi organ dysfunction syndrome)

Sources of Infection
1) Primary acquired from community or

endogenous. 2)Secondary exogenous, acquired from operation theatre 0r ward (nosocomial)or contamination at surgery. they arise from organism being introduced in to tissues due to inadequate wound care after surgery(c0mmon cause is poor hand washing)

Criteria for defining SSIs

surgical site infections


3rd most common nosocomial infection

14-16% Most common nosocomial infection among surgery patients 38% 2/3 incisional 1/3 organ

Further Classification
Etiology

a) Primary The wound is the primary site of infection b)Secondary Infection arises following a complication that is not directly related to wound

Contd;
Time

a) Early Infection presents within 30 days of procedure b) Intermediate Occurs between one and three months c) Late Presents more than three months after surgery

Contd;
Severity

a) Minor Wound infection is described as minor when there is discharge without cellulitis or deep tissue destruction b) major When there is pus discharge with tissue breakdown , Partial or total dehiscence of the deep fascial layers of wound or if systemic illness is present.

Wound assesment
For surgical wound assesment several scoring systems

are employed especially a) Asepsis scoring b) Southampton wound assessment scale These enable surgical wound healing to be graded according to specific criteria, usually giving a numerical value, thus providing more objective assessment of wound.

Common bacteria in wound infection.


1)Strepococci

gram positive chains hemolytic streptococci is imp and reside in pharynx of5-10% population. --Streptococcus pyogenes has tendency to spread by cellulitis and cause tissue disstuction through release of strepocolysin,streptokinase and streptodornase. (cond)

Strep fecalis is an enterococcus and often found in

synergy with other organisms. -- Both Strepto pyogenes and Strep.faecalis may be in volved in wound infection after large bowl surgery. --- All Strepto cocci are sensitive to penicillins and Erythromycin and cephalosporins in pt who are allergic to penicilline.

Streptococci

Strepto cocci

Stephylococci
Forms clumps and Gram positive cocci.
--St.aureues in most imp pathogen and

found in 15% of population . -- It can cause exogenous suppuration in wound and implanted prostheses. --strains resistant to antiboitic Eg MRSA can cause epidemics. -- some MRSA step are resistant to Vancomycin.

-- Most infections are localized (wound abscess)


---Most hospital Steph.aureus strains are now

lactamase producers and resistant to penicilline. --- Even now sensitivity to flucloxacilline,vancomycin,aminoglycosides.some cephalosporin's and fusidic acid remain high. --Staph. Epidermis (Steph .albus) and most coagulase negative stephalococci are as commensels but now recognised as major threat to prostheses.They exists in hospital and nosocomially acquired organisms.and resistant to many antiboitics.

Strphalococci

Stephalococci

CLOSTRIDIA
Clostridia organisms are Gram-positive obligate

anaerobes which produce resistant spores. Clostridium tetani causes Tetanus following implantation in tissue or wound by release exotoxin Tetanospasmin -- c.perfingens cause gas gangrene , gram positive spore bearing bacilli widly found in nature particularly soil and faeces. -- relevant to military and traumatic and colo rectal surgery.

Gas gangrene

Aerobic gram negative bacilli(AGNB)


1)They are normal inhabitants of large bowl.
2)most organisms in this group act in synergy with

bacteriods to cause wound infection after bowl surgery particularly after appendicitis ,diverticulitis and peritonitis. 3)psudomonas tend to colonise burns,treacheostomy wounds, and urinary tract. 4)psudomonas infection rates may be regarded as markers of hospital hygiene standards.

5)once pseudomonas has colonized wards and

intensive care units it may be difficult to erradicate. 6)Hospital infections become resistant to lactamase and resistance can be transferred by plasmids. 7)wound infection needs antibiotic therapy only when there is progressive or spreading infection with systemic signs,

Bacteroides
-- Non-spore bearing strict anaerobes that colonize

large bowl,vagina and oropharynx. --- Bacteroides fregilis is the organism that act in surgery with AGNB(anearobic gram negative bacilli) to cause wound infection after colorectal and gyneacological surgery. -- sensitive to Metronidazole and cephalosporins.

Pathogenesis
Virulence

Bacterial dose

Impaired host resistance

Risk factors
Patient factors
Diabetes Obesity

Nicotine use
Steroid use Malnutrition

Hospital stay
Nares colonization with S. aureus Transfusion

Preop factors
Preoperative antiseptic showering
Preoperative hair removal Patient skin preparation in the operating room

Preoperative hand/forearm antisepsis


Antimicrobial prophylaxis

Preoperative antiseptic showering

Decreases skin microbial colony counts No evidance of benefit to reduce SSI rates
Preoperative hair removal

Shaving: @ immediately before the operation: SSI rates 3.1% @ shaving within 24 hours preoperatively: 7.1% @ having performed >24 hours: SSI rate > 20%. Depilatories: @ lower SSI risk than shaving or clipping @ hypersensitivity reactions

Prophylactic antibiotics
Class 1 = Clean
Class 2 = Clean contaminated Class 3 = Contaminated
Prophylactic antibiotics indicated

Class 4 = Dirty infected Therapeutic antibiotics

Wound Classification

Antibiotic 1st generation Cephalosporin 1st generation Cephalosporin 2nd generation Cephalosporin

PCN Allergy Vancomycin Clindamycin Vancomycin Clindamycin


Aztreonam and Clindamycin/Flagyl

I II-Biliary,GU, Upper Digestive II-Distal Digestive


III/IV

Generally Therapeutic

Once the incision is made, antibiotic delivery to the wound is impaired. Must give before incision!

ABX

Operative characteristics
Operating room environment
Surgical attire and drapes Asepsis and surgical technique

Operating room environment


Ventilation

@ Positive pressure with respect to corridors and adjacent areas Environmental surfaces @ Rarely implicated as the sources of pathogens important in the development of SSIs. @ Important to perform routine cleaning of these surfaces Conventional sterilization of surgical instruments @ Inadequate sterilization of surgical instruments has resulted in SSI outbreaks

Surgical attire and drapes


The use of barriers: @ patient: minimize exposure to the skin, mucous membranes, or hair of surgical team members @ surgical team members: protect from exposure to blood and bloodborne pathogens.

Asepsis and surgical technique


Rigorous adherence to the principles of asepsis by all scrubbed personnel Excellent surgical technique: reduce the risk of SSI. Drains: increase incisional SSI risk.

Postoperative issues
Incision care The type of postoperative incision care @ closed primarily: the incision is usually covered with a sterile dressing for 24 to 48 hours. @ left open to be closed later: the incision is packed with a sterile dressing. @ left open to heal by second intention: packed with sterile moist gauze and covered with a sterile dressing.

Treatment surgical site infection

Efflux of purulent material and pus Fascia is intact: debridement Irrigated with N/S and packed to its base with saline-moistened gauze Fascia separated: drainage or reoperation Most SSIs: healing by secondary intention

Discharge planning
The intent of discharge planning:

maintain integrity of the healing incision, educate the patient about the signs and symptoms of infection, advise the patient about whom to contact to report any problems.

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