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SURGICAL AND NOSOCOMIAL INFECTION

Miradz Hudaya., dr Diki Zulkarnain., dr Billy Yacub Rafel Talakua., dr

HISTORICAL BACKGROUND

Reducing the mortality associated with surgery : Preventing microbial penetration Reducing the microbial inoculum Treating established infection

The Famous Names of Surgical and Nosocomial Infection


Ignaz Semmelweis 1846 Louis Pasteur 1849 Germ Theory Joseph Lister 1859 Robert Koch 1867 Charles Mc Burney 1889 Source Control

Pathophysiology of infection
Three factor must be exist : 1. An inoculum of pathogens Sufficient number Virulence 2. A nutrient medium on which microbes can thrive 3. Some alteration in host resistance must accur

Host Defenses
Host defenses are important in preventing mikrobial penetration into the tissue lokal host defenses tissue are protected from microbal invasion by a layer of epithelium systemic host defenses consist of phagositic cells, the imun system,complement system, coagulation and the kinin system

Surgical Infection
Infections that require operative treatment Infections that result from operative treatment

Infections that require operative treatment


1. Necrotizing soft tissue infection
2. Body cavity infections

peritonitis, supurative pericarditis, empyema 3. tissue, organ and joint infections abscess, septic arthritis 4. Prosthetic device-associated infections

Infections that result from operative treatment


1. Wound infections
2. Postoperative abscess 3. Postoperative peritonitis

4. Postoperative body cavity infection


5. Prosthetic device related infections

1. 2. 3.

4.

The development of surgical infection depends on: Microbial pathogenicity and number Host defences the local environtment Surgical technique

Microbial pathogenicity some mikrobes have virtually no ability to cause infection in normal host can cause lethal infection in an individual with compromised host defense

Host defenses are important in preventing mikrobial penetration into the tissue lokal host defenses tissue are protected from microbal invasion by a layer of epithelium systemic host defenses consist of phagositic cells, the imun system,complement system, coagulation and the kinin system

Local environmental factors may permit an infection to occur in a person with minimal microbial contamination & with otherwise adequate host defense A suture can reduce the number os S.aureus Fluid collection & edema infection , cause inhibit fagositosis

Surgical technique surgeon can reduce likelihood infection: handling tissue gently removing devitalized tissue, blood,etc using drain appropriately

Type of Surgical Infections 1. Soft tissue infections Cellulitis and Lymphangitis soft tissue abscess necroting soft tissue infection Tetanus 2. Body cavity infection Peritonitis and intrabdominal Empyema

Cellulitis & Lymphangitis spreading infection of the skin and subcutaneus tissue caused by Strep. Pyogenes, S.aureus, Strep.pneumonia, H.influenzae and aerobic and anaerobic gram negative bacteria

Soft tissue abscess -> mostly found on the back -> most common cause by Stap.aureus

Necrotizing soft tissue infections most caused by mixed aerobic and an aerobic gram negative and gram positive bacteria. Clostridium spesies

Peritonitis and intraabdominal abscess primary peritonitis caused by a single organism most common in young children and adults with ascites or CRF Secondary bacterial peritonitis ussualy the result of a defect in GIT Tertiary peritonitis peritonitis like synd. result of disturbance host immune response caused by fungi or low grade pathogenic bacteria

Empyema ussualy due to pneumonia treatment -> evacuation

Treatment of Surgical Infection


Resuscitation Appropiate use of antimicrobial agents Source control

NOSOCOMIAL INFECTION

Definition Tranmission of pathogen organism to the patient no had infection before. Clasification of nosokomial infection Community based acquire infection Hospital based acquire infection Operating based room acquire infection

PATHOPHYSIOLOGY
The two key features contributing to the development of N.I
1. Reduction in the patients normal immune or defense systems 2. Colonizations by pathogenic or potentially pathogens

Specific Nosocomial Infection


Urinary tract infections Lower Respiratory tract Infection (nosocomial pneumonia) Bloodstream infection (venous line) Surgical site infection others

Wound classification
Wound Class Expected infection Rates 1,0 - 5,4 % 2,1 - 9,5 % 3,4 - 13,2 % 3,1 - 12,8 %

CLEAN CLEAN CONTAMINATED CONTAMINATED DIRTY

Superficial surgical Wound Infection An incisional wound infection occurs within 30 days after operation involves skin or subcutaneous tissue above the fascial layer & any of the following 1. There is purulent drainage from the incision or a drain located above the fascial layer. 2. An organism is isolated from culture of fluid that has been aseptically obtained from a wound that was closed primarily. 3. The wound is opened deliberately by the surgeon, unless the wound is culture-negative.

Superficial surgical Wound Infection

Deep surgical wound infection occurs within 30 days after operation, involves tissues or spaces at or beneath the fascial layer and any of the following 1. The wound spontaneously dehisces or is deliberately opened by the surgeon when the patient has a fever (>38C) and/or there is localized pain or tenderness, unless the wound is culture-negative. 2. An abscess or other evidence of infection directly under the incision is seen on direct examination, during operation, or by histopathologic examination. 3. The surgeon diagnoses infection.

Deep surgical wound infection

How to prevent Infection


Human character Regulations Antibiotic prophylaxis Good Surveillance system

General approach to therapy: prevention as its primary goal


Source control 1. Remove/treat infection 2. Remove/treat inflammation 3. Remove dead tissue 4. Stabilize injured tissue 5. Restore microcirculation Nutrition/metabolic support 1. Achieve nitrogen balance 2. Avoid calorie overload 3. Avoid long-chain fat overload 4. Appropriate vitamins, minerals, trace elements Resuscitation 1. Minimize flow-dependent oxygen consumption 2. Minimize flow-dependent lactate clearance

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