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Surgical Infection

Schwartzs principle of surgery 10th edition

(chapter 6)

Sepsis is both the presence of infection and the host
response to infection (systemic inflammatory response
syndrome, SIRS).
Sepsis is a clinical spectrum, ranging from sepsis (SIRS
plus infection) to severe sepsis (organ dysfunction), to
septic shock (hypotension requiring vasopressors).
Outcomes in patients with sepsis are improved with an
organized approach to therapy that includes rapid
resuscitation, antibiotics, and source control.

Source control is a key concept in the treatment of most
surgically relevant infections.
Infected or necrotic material must be drained or
removed as part of the treatment plan in this setting.
Delays inadequate source control are associated with
Worsened outcomes

Pathogenesis of Infection
Host Defenses
skin or subcutaneous tissue are common. The mammalian
possesses several layers of endogenous defense
mechanisms that serve to prevent microbial invasion, limit
proliferation of microbes within the host, and contain or
eradicate invading microbes.
Infection is defined by the presence of microorganisms
in host tissue or the bloodstream. At the site of infection
the classic findings of rubor, calor, and dolor in areas such as
the skin or subcutaneous tissue are common

Relationship between infection and systemic inflammatory response

syndrome (SIRS).
Sepsis is the presence both of infection and the systemic inflammatory
response, shown here as the intersection of these two areas. Other conditions
may cause SIRS as well (trauma, aspiration, etc.). Severe sepsis (and septic

Criteria systemic inflammatory

response syndrome
General variable
Fever (core temp > 38,3oC)
Hypothermia (core temp < 36oC)
Heart rate > 90 bpm
Altered mental status
Significant edema or positive fluid balance (>20 mL/kg over 24 h)
Hyperglycemia in the absence of diabetes
Inflammatory variable

Leukocytosis (WBC >12,000)

Leukopenia (WBC <4000)
Bandemia (>10% band forms)
Plasma C-reactive protein >2 s.d. above normal value
Plasma procalcitonin >2 s.d. above normal value

Criteria systemic inflammatory response syndrome

Hemodynamic variable
Arterial hypotension (Systolic Blood Pressure <90 mm Hg, MAP <70, or Systolic Blood
Pressure decrease >40 mmHg)

Organ dysfunction variables

Arterial hypoxemia
Acute oliguria
Creatinine increase
Coagulation abnormalities

Tissue perfusion variables

Decreased capillary filling

Microbiology Of Infectious
Bacteria are responsible for the majority of surgical
infections. Specific species are identified using Grams
stain and growth characteristics on specific media.
Bacteria are classified based upon a number of
additional characteristics, including morphology (cocci
and bacilli), the pattern of division (e.g., single
organisms, groups of organisms in pairs [diplococci],
clusters [staphylococci], and chains [streptococci]), and
the presence and location of spores

Microbiology Of Infectious
Fungi typically are identified by use of special stains (e.g.,
potassium hydroxide (KOH), India ink, methenamine silver, or
Giemsa). Initial identification is assisted by observation of the
form of branching and septation in stained specimens or in
Viral infection was identified by indirect means (i.e., the host
antibody response).

Common pathogen in surgical


Surgical Site Infections (SSIs)

Infections of the tissues, organs, or spaces exposed by
surgeons during performance of an invasive procedure.
SSIs are classified into incisional and organ/space infections,
and the former are further sub classified into superficial
(limited to skin and subcutaneous tissue) and deep incisional
The development of SSIs is related to three factors :
(a) the degree of microbial contamination of the wound during
(b) the duration of the procedure, and
(c) host factors such as diabetes, malnutrition, obesity, immune
suppression, and a number of other underlying disease states.

Surgical wounds
Classified based on the presumed magnitude of
the bacterial load at the time of surgery:
Clean wounds (class I) include those in which no
infection is present; only skin microflora potentially
contaminate the wound, and no hollow viscus that
contains microbes is entered.
Class I D wounds are similar except that a prosthetic device
(e.g., mesh or valve) is inserted.

Clean/contaminated wounds (class II) include

those in which a hollow viscus such as the respiratory,
alimentary, or genitourinary tracts with indigenous
bacterial flora is opened under controlled

Contaminated wounds (class III) include open accidental

wounds encountered early after injury, those with extensive
introduction of bacteria into a normally sterile area of the
body due to major breaks in sterile technique (e.g., open
cardiac massage), gross spillage of viscus contents such as
from the intestine, or incision through inflamed, albeit
nonpurulent tissue.
Dirty wounds (class IV) include traumatic wounds in which
a significant delay in treatment has occurred and in which
necrotic tissue is present, those created in the presence of
overt infection as evidenced by the presence of purulent
material, and those created to access a perforated viscus
accompanied by a high degree of contamination.


General Principles

Maneuvers to diminish the presence of exogenous







endogenous (patient) microbes are termed prophylaxis,

and consist of the use of mechanical, chemical, and
antimicrobial modalities, or a combination of these


Source Control

The primary precept of surgical infectious disease therapy consists

of :
drainage of all purulent material
debridement of all infected
devitalized tissue, and debris, or removal of foreign bodies at the
site of infection
plus remediation of the underlying cause of infection.

Principles relevant to appropriate

antibiotic prophylaxis for surgery:
select an agent with activity against organisms
commonly found at the site of surgery
the initial dose of the antibiotic should be given within
30 minutes prior to the creation of the incision
the antibiotic should be redosed during long operations
based upon the half-life of the agent to ensure adequate
tissue levels
the antibiotic regimen should not be continued for more
than 24 hours after surgeryfor routine prophylaxis

Principle using antimicrobial agent

for therapy of serious infection:
identify likely sources of infection
select an agent (or agents) that will have efficacy against likely
organisms for these sources
inadequate or delayed antibiotic therapy results in increased
mortality, so it is important to begin therapy rapidly with broader
when possible, obtain cultures early and use results to refine therapy
if no infection is identified after 3 days, strongly consider
discontinuation of antibiotics, based upon the patients clinical
Discontinue antibiotics after an appropriate course of therapy

The incidence of surgical site infections can be reduced by:

appropriate patient preparation

timely perioperative antibiotic administration
maintenance of perioperative normothermia and normoglycemia
appropriate wound management.

The keys to good outcomes in patients with necrotizing soft

tissue infection are early recognition and appropriate
debridement of infected tissue with repeated
debridement until no further signs of infection are present.