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SURGICAL INFECTIONS

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  1. SURGICAL INFECTIONS Begashaw M (MD)

  2. Surgical infection • Defined as aninfection related to or complicating a surgical therapy and requiring surgical management • Related to surgical therapy but may not require surgery - UTI after catheterization • Pulmonary CXN after intubation • Tracheotomy site infection • Post-operative wound infection

  3. CLASSIFICATION • Pre operative infections:before a surgical procedure - Accidents - Appendicitis - Boils - Carbuncle - Pyomyositis

  4. Operative infections Happen during a surgical procedure Due to -contamination of the site -poor tissue handling

  5. Postoperative infections Occur after a surgical procedure Contamination is from the patient’s source e.g - Surgical wound infections - Urinary & respiratory tract infection

  6. PATHOGENESIS • Elements or factors include: - An infectious agent - A susceptible host - Favorable external factors/ environment

  7. Infectious agents 1- Aerobic bacteria - Staphylococcus aureus - Streptococci - Klebsiella - E. coli 2- Anaerobic bacteria - Bacteroides - Peptostreptococci - Clostridia

  8. Infectious agents 3- Fungi - Histoplasma - Candida - Nocardia and actinomycetes 4- Parasites - Entamebahystolytica-amebic liver abscess - Echinococcus - hydatid cyst

  9. Host Susceptibility • Reduced immunity/host defense -Diabetes mellitus -TB -AIDS

  10. Local and external factors • Local factors - Poor vascularization - Poor perfusion of blood and oxygen - Dead tissue - Foreign bodies - Closure under tension • External factors-break in the sterility technique

  11. Clinical manifestation Hotness, redness, edema/swelling,pain & loss of function Non-Specific symptoms- Fever, chills, tachycardia Constitutionalsymptoms - Fatigue, low-grade fever

  12. Investigations WBC count: usually elevated Gram stain ,culture & sensitivity Blood culture:bacterermia Biopsy: Histologic X-ray and ultrasound

  13. Post-Operative Wound Infection Is contamination of a surgical wound during or after a surgical procedure Is usually confined superficial Below the fascia - deep infection

  14. Types of Surgical Site Infections

  15. Source of infection 80% cases - patient (Endogenous) -skin ,transected viscus. In about 20% cases - Exogenous -environment -operating staff -unsterile surgical equipment

  16. Clinical Findings • On the 5th-7thpostoperativeday - Fever - Wound pain - Wound edema and induration - Local hotness and tenderness - Wound/stitch abscess - Serous discharge - Crepitation

  17. Wound infection

  18. Management - Remove stitches to allow drainage - Local wound care - Antibiotics-if systemic manifestations/cellulitis

  19. Prevention Shorten preop. Hospitalization Loose weight Treatment of remote infection Shorten operative time Restore host defense Decrease endogenous bacterial cont. Good surgical technique Proper asepsis and antisepsis Chemoprophylaxis

  20. Abscess Localized collection of pus Contains necrotic tissue & suppuration Etiology -Pyogenic organisms - staphylococci

  21. Abscess

  22. Clinical features - Superficial (Hot, pain, edema, rednessand loss of function) - Fluctuation - Discharge & sinus - Systemic - fever, sweating, tachycardia

  23. Treatment - Drainage byincision - Debridement & curettage - Delayed primary or secondary closure - Antibiotics - systemic symptoms or signs of spread occur-cloxacillin

  24. Abcsess drainage

  25. Abscess drainage

  26. Erysipelas _ Acute skin infection that is more superficial than cellulitis _ Etiology - Group A Streptococcus (GABHS) _Clinical Features Intense erythema, induration, & sharply demarcated borders _Treatment - penicillin or first generation cephalosporin - cephalexin

  27. Eryspelas

  28. Cellulitis • Non-suppurative infection of skin and subcutaneous tissues • Usually involves the extremities • Identifiable portal of entry • Etiology: skin flora - Beta hemolytic streptococci - Staphylococci - Clostridium perfringens

  29. Clinical Features Source of infection -trauma, recent surgery -diabetes - cracked skin -foreign bodies Systemic - fever, chills, malaise Pain, tenderness, edema, erythema with poorly defined margins

  30. cellulitis

  31. Cellulitis

  32. Investigation • CBC, blood cultures • Culture and Gram stain • Plain radiographs- R/o osteomyelitis • CellulitisVs Eryspela -Cellulitis: indistinct border -Erysipela: sharp boarder

  33. Management - Rest - Elevation/immobilize - Hot, wet pack - High dose broad spectrum antibiotics IV _Cloxacillin 500 mg QID/cephalexin

  34. Pyomyositis • Acute bacterial infection of skeletal muscles with accumulation of pus inthe intramuscular area • Occurs in the lower limbs &trunk • Associated factors-Poor nutrition -immune deficiency -hot climate -intense muscle activity

  35. Etiology -Staphylococcus aureus - common -Streptococci

  36. Clinical Features • Sub-acute onset • Localized muscle pain & swelling • Tenderness • Induration, erythema, heat • Muscle necrosis • Fever

  37. Pyomyositis

  38. Treatment • Intravenous antibiotics- cloxacillin • Surgical drainage • Excision -necrotic muscle • Supportive care-analgesics

  39. Necrotizing fasciitis • Rapidly spreading, very painful infection of the deep fascia with necrosis of tissues • Some bacteria create gas that can be felt as crepitus • Infection spreads rapidly along deep fascial plane and is limb and life threatening

  40. Etiology • Polymicrobial - Streptococci- hemolytic - Staphylococci - Gram negative bacteria - Anaerobes - Clostridia

  41. Clinical Features Pain out of proportion Erythema, edema, tenderness, ± crepitus ±fever Infection spreads very rapidly Rapidly become very sick/toxic Skin turns dusky blue and black (secondary to thrombosis & necrosis) Induration, formation of bullae Cutaneous gangrene, subcutaneous emphysema

  42. Necrotizing fascitis

  43. Treatment Rigorous resuscitation Multiple surgical debridement: remove all necrotic tissue, copious irrigation IV antibiotics-Ceftriaxone +Metronidazole

  44. Gas Gangrene Characterized by muscle necrosis and systemic toxicity Follows - Trauma - Surgery - Foreign bodies - Vascular insufficiency

  45. Etiology -Clostridium perfringens -80% of cases - polymicrobial infection

  46. Clinical features - Sudden and persistent severe pain at wound site - Localized tense edema, pallor , tenderness - Gas noted on palpation or radiograph - brownish discoloration of skin and hemorrhagic bullae - Dirty brown discharge with offensive, sweetish odor - Systemic - fever, tachycardia,hypotension

  47. Gas on soft tissue

  48. Management • Surgery - important -Extensive, wide excision -Amputation -Antibiotic -Supportive - Intravenous infusions - Blood transfusions - Close monitoring

  49. TETANUS 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 Anxious look with mouth drawn up ( risussardonicus) Respiration & swallowing progressively difficult Reflex convulsions along with tonic spasm Death by exhaustion, aspiration or asphyxiation