SURGICAL INFECTIONS & ANTIBIOTICS

1. SURGICAL INFECTIONS&ANTIBIOTICS M K ALAMMS, FRCS Prof. & Consultant Surgeon College of Medicine & RCH 428 surgery team Done by : 428 surgery team

2. 428 surgery team OBJECTIVES • Definitions. • Pathogenesis . • Clinical features . • Surgical microbiology. • Common infections. • Antibiotics use.

3. 428 surgery team INFECTION Invasion of the body by pathogenic microorganisms and reaction of the host to organisms and their toxins ( the def. its 2 part :1- invase of organism 2- body respond to it )

4. 428 surgery team SURGICAL INFECTIONS Infections that require surgical intervention as a treatment [1] or develop as a result of surgical procedure [2]. Appendicitis: 1- comes? the infection – need treatment by surgery 2- surgery – complictaion

5. 428 surgery team Surgical Infection • A major challenge • Accounts for 1/3 of surgical patients • Morbidity increase • Mortality increase • Increased cost to healthcare

6. 428 surgery team Factors contributing to infections • Microorganism related factors: -Adequate dose ( many organism ) -Virulence of microorganisms • Host related factors: -Suitable environment ( closed space ) ( make an env. For the body to accept the organism ) . -Susceptible host ( weak immunity )

7. 428 surgery team Pathogenicity of bacteria ( wt makes organism pathogen ?) -Exotoxins:specific effect for each bacteria type , soluble proteins, remote cytotoxic effect , released from intact bacteria e.g Cl.Tetani cause tetanus, Strep. Pyogenes cause infection having an acid -Endotoxins:part of gram-negative bacterial wall, released only after destruction of bacteria , lipopolysaccharides e.g., E coli Resist phagocytosis:Protective capsule Klebsiela and Strep. Pneumoniae -Explain: 1- toxin ----- EX. Secretions ---- END. Part of the organism which distorted it 2- resist phagocytosis

8. 428 surgery team Host Resistance • Intact skin / mucous membrane. (surgery/ trauma- causes breach) by breaking the skin during the surgery which is a defensive mechanism for the body . • Immunity: like patient who treated by cortisone , they have weak immunity Cellular (phagocytes ) Antibodies

9. 428 surgery team Classification of infection - Autoinfection(endogenous) :pathogen from within the patient - Community acquired : e.g. flu -nosocomial : from hospital environment -iatrogenic : secondary to theraby e.g. cathters - From carrier - Opportunistic infection

10. 428 surgery team Clinical features • Local- pain, heat, redness, swelling, some times loss of function. (apparent in superficial infections) • Systemic- ill , loss of appetite , fever, tachycardia, chills,rigors • Like appendicitis when patient come after 3 days with high fever this indicate as infection .

11. 428 surgery team Principles of surgical treatment • Debridement- necrotic, injured tissue [a] • Drainage- abscess, infected fluid [b] • Removal- infection source, foreign body[c] • Supportive measures: to stop the spread of infection • a- immobilization “ bed rest “ • b- elevation “ swell less , rest elevation “ • c- antibiotics “ for appendicitis “

12. 428 surgery team STREPTOCOCCI • Gram positive, manilyaerobe/anaerobe • Flora of the mouth and pharynx oral cavity , ( bowel ) • Streptococcus pyogenes–( β hemolytic) 90% - 95% of infections e.g.,lymphangitis, cellulitis, rheumatic fever,pharyngitis • Strep. viridens-subacute bacterial endocarditis, urinary infection • Strep. Fecalis(bowel ) – urinary infection, pyogenic infection • Strep. pneumonae – pneumonia, meningitis not commonly seen

13. 428 surgery team STAPHYLOCOCCI “ surgical wound infections “ • Inhabitants of skin, Gram positive anaerobes • Infection characterized by suppuration like HAI, immune weak • Staph.aureus- the most common , most pathogen SSI, nosocomial ,superficial infections • Staph. epidermidis- opportunistic ( wound, endocarditis )

14. 428 surgery team CLOSTRIDIA • Gram positive, anaerobe • Rod shaped microorganisms • Live in bowel & soil • Produce exotoxin for pathogenicity • Important members: Cl. Perfringens, Cl. Septicum ( gas gangrene ) Cl. Tetani ( tetanus ) Cl. Difficile ( pseudomembranous colitis )

15. 428 surgery team GRAM NEGATIVE ORGANISMS( Enterobactericiae ) Escherichia coli ( bowel infections ) Facultative anaerobe, Intestinal flora Produce exotoxin & endotoxin Endotoxin produce Gram-negative shock Wound infection, abdominal abscess, UTI, meningitis, endocarditis Treatment- ampicillin, cephalosporin, aminoglycoside

16. 428 surgery team GRAM NEGATIVE ORGANISMS Pseudomonas most come in ICU patient • aerobes, occurs on skin surface • opportunistic pathogen • may cause serious & lethal infection • colonize ventilators, iv catheters, urinary catheters • Wound infection, burn, septicemia • Treatment: aminoglycosides, piperacillin, ceftazidime

17. 428 surgery team GRAM NEGATVE ANAEROBESBacteroidesfragilis( bowel surgery , investigation by abscess with bad smell ) • Normal flora in oral cavity, colon • Intra-abdominal & gynecologic infections ( 90% ) • Foul smelling pus, gas in surrounding tissue, necrosis • Spiking fever, jaundice, Leukocytosis • No growth on standard culture • Needs anaerobe culture media • Treatment: Surgical drainage Antibiotics- clindamycin, metronidazole

18. 428 surgery team TYPES OF SURGICAL INFECTION • A. Surgical Site Infection • B. Soft Tissue Infection • C. Body Cavity Infection • D. Prosthetic Device related Infection • E. Miscellaneous

19. 428 surgery team Surgical site infection (SSI) • 38% of all surgical infections • Infection within 30 days of operation • Classification: - Superficial: Superficial SSI–infection in subcutaneous plane (47%) - Deep:Subfascial SSI-muscle plane (23%) Organ/ space SSI-intra-abdominal, chest infections ,other spaces (30%) • Staph. aureus- most common organism • E coli, Entercoccus ,other Entetobacteriaceae- deep infections B fragilis – intrabd. abscess

20. 428 surgery team Surgical site infection (SSI) • Risk factors: age, malnutrition, obesity, immunocompromised, poor surg. tech, prolonged surgery, preop. shaving and type of surgery. • Diagnosis: Sup.SSI- erythema, oedema, discharge and pain Deep infections- no local signs, fever, pain, hypotension. need investigations. • Treatment: surgical / radiological intervention.

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22. 428 surgery team Prevention of SSI • Pre-op: Treat pre-existing infection Improve general nutrition Shorter hospital stay Pre-op. shower Hair removal timing? Should if the surgery take long time , or the area need to shave. • Intraoperative: Antiseptic technique Surgical technique • Post-operative: Hand hygiene

23. 428 surgery team STREPTOCOCCAL INFECTIONSErysipelas • Superficial spreading cellulitis & lymphangitis • Area of redness, sharply defined irregular border • Follows minor skin injuries • Strep pyogenes • Common site: around nose extending to both cheeks • Penicillin, Erythromycin

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25. 428 surgery team SREPTOCOCCAL INFECTIONCellulitis • Inflammation of skin & subcutaneous tissue • Non-suppurative • Strep. Pyogenes • Common sites- limbs • Affected area is red, hot & indurated • Treatment : Rest, elevation of affected limb Penicillin, Erythromycin Fluocloxacillin ( if staph. suspected )

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27. 428 surgery team NECROTIZING FASCIITIS • Necrosis of superficial fascia, overlying skin • Polymicrobial : Streptococci (90%), anaerobic Grampositive Cocci, aerobic Gram-negative Bacilli, and the Bacteroides spp. • Sites- abd.wall (Meleny’s), perineum(Fournier’s), limbs, • Usually follows abdominal surgery or trauma

28. 428 surgery team NECROTIZING FASCIITISwe have 2 do the investigation 2 differentiated from simple crllulitis • Diabetics more susceptible • Starts as cellulitis, edema, systemic toxicity • Appears less extensive than actual necrosis • Investigation: Aspiration, Gram’s stain, CT, MRI • Treatment: IV fluid, IV antibiotics (ampicillin, clindamycin l metronidazole, aminoglycosides ) Debridement , repeated dressings, skin grafting

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30. STAPHYLCOCCAL INFECTIONS Abscess-localized a lot creamy pus collection Treatment- drainage, antibiotics Furuncle- infection of hair follicle / sweat glands Carbuncle- extension of furuncle into subcut. tissue common in diabetics common sites- back, back of neck Treatment: drainage, antibiotics, control diabetes 428 surgery team

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32. 428 surgery team GAS GANGRENE grame (+) anaerobe • Cl. Perfringens, Cl. Septicum • Exotoxins: lecithinase, collagenase, hyaluridase • Large wounds of muscle ( contaminated by soil, foreign body ) • Charcterized by progressive ,rapidly spreading edema • Rapid myonecrosis (Affect mainly muscle and cause muscle necrosis) , crepitus in subcutaneous tissue • Seropurulent discharge, foul smell, swollen • Toxemia, tachycardia, ill looking • X-ray: gas in muscle and under skin • Treatment : • - Penicillin, clindamycin, metronidazole -Wound exposure, debridement , drainage, amputation -Hyperbaric oxygen chamber

33. 428 surgery team TETANUS gram + , not seen recently unless u didn’t get the vaccine , or didn’t take the booster • 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 muscle spasm • Anxious look with mouth drawn up ( risussardonicus) • Respiration & swallowing progressively difficult • Reflex convulsions along with tonic spasm • Death by exhaustion, aspiration or asphyxiation

34. 428 surgery team • risus sardonicus Contraction of jaws >> become closed.. While the lips >> open & tooth visible .

35. 428 surgery team TETANUS • Treatment: wound debridement, penicillin Muscle relaxants, ventilatory support Nutritional support • Prophylaxis: wound care, antibiotics Human tetanus immunglobulin (HTIG )in high risk ( un-immunized ) Commence active immunization ( T toxoid) Previously immunized- booster >10 years needs a booster dose booster <10 years- no treatment in low risk wounds

36. 428 surgery team PSEUDOMEMBRANOUS COLITIS gram + • Cl. Difficile • Overtakes normal flora in patients on antibiotics • Watery diarrhea, abdominal pain, fever • Sigmoidoscopy show: membrane of exudates (pseudomembranes) • Diagnosis :Stool- culture and toxin assay • Treatment : stop offending antibiotic oral vancomycin/ metronidazole rehydration, isolate patient

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38. 428 surgery team Body Cavity Infection abdominal and • Primary peritonitis: Spontaneous, weak immune . Children, Ascitic immuno Haematogenous/ lymphatic route Tt /Antibiotic • Secondary peritonitis: infectionone of the organ in abdomen Inflam./ rupture of viscera Polymicrobial Investigations: blood, radiological Tt/ of original cause

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41. 428 surgery team Prosthetic Device Related Infection • Artificial valves and joints • Peritoneal and haemodialysis catheters • Vascular grafts patientmay have hernia repair • Staphylococcus aureus • Antibiotics, washing of prosthesis or removal

42. 428 surgery team Hospital Acquired Infection • Occurring within 48 h of hospital admission, three days of discharge or 30 days following an operation • 10% of patients admitted to hospitals • Spent 2.5-times longer in hospital - UK • Highest prevalence in ICU- • Enterococcus, Pseudomonas spp.,E coli(exo & endo toxin), Staph. aureus. • Sites: Urinary, surg. Wounds, resp., skin, blood, GIT Wt is the most common site in HAI ?

43. 428 surgery team ANTIBIOTICS Chemotherapeutic agents that act on organisms • Bacteriocidal: Penicillin, Cephalosporin, Vancomycin Aminoglycosides • refers to the treatment of a bacterium such that the organism is killed • Bacteriostatic: Erythromycin, Clindamycin, Tetracycline • refers to a treatment that restricts the ability of the bacterium to grow

44. 428 surgery team ANTIBIOTICS THE DOC SAID READ IT • Penicillins- Penicillin G, Piperacillin • Penicillins with β-lactamase inhibitors- Tazocin • Cephalosporins (I, II, III)- Cephalexin, Cefuroxime, Ceftriaxone • Carbapenems- Imipenem, Meropenem • Aminoglycosides- Gentamycin, Amikacin • Fluoroquinolones- Ciprofloxacin • Glycopeptides- Vancomycin • Macrolides- Erythromycin, Clarithromycin • Tetracyclines- Minocycline, Doxycycline

45. 428 surgery team ROLE OF ANTIBIOTICS “ given a scenario and ask if its therapeutic or prevention” • Therapeutic:To treat existing infection • Prophylactic ( PREVENTION ) :To reduce the risk of wound infection

46. 428 surgery team ANTIBIOTIC THERAPY • Pseudomembranous colitis- oral vancomycin/ metronidazole • Biliary-tract infection-cephalosporin or gentamycin • Peritonitis- cephalosporin/ gentamycin + metronidazole/ clindamycin • Septicemia- aminoglycoside + ceftazidime, Tazocin or imipenem, ( may add metronidazole ) • Septicemia due to vascular catheter- Flucloxacillin/ vancomycin or Cefuroxime • Cellulitis- penicillin, erythromycin ( flucloxacillin if Staphylococcus infection. Suspected )

47. 428 surgery team ANTIBIOTIC PROPHYLAXISBASED ON SURGICAL WOUND CLASSIFICATION • Clean wound no organism present - e.g., thyroid surgery ( 2% ) , repair of hernia , removing a laparotomy(NOT in GIT ,Resp. Sys. , or GU sys). • Typically an elective surgery in a non-contaminated, non-traumatic and non-inflamed surgical site • Clean-contaminated-minimal contamination e.g., biliary, urinary, GI tract surgery ( 5-10% ) • Here surgery involves the respiratory, GI or genitourinary system, ie often a hollow organ • Contaminated-gross contamination e.g., during bowel surgery- (up to 20% ) • Similar surgeries, but with leakage or a major break in aseptic technique • Dirty- surgery through established infection e.g., peritonitis ( up to 50% ) NOT prophylaxis BUT antibiotic • A hollow organ is ruptured  

48. 428 surgery team ANTIBIOTIC PROPHYLAXIS (IMP ) * Prophylaxis in clean-contaminated/ high risk clean wounds * Antibiotic is given just before patient sent for surgery *Duration of antibiotic is controversial ( one dose- 24 hour regimen ) *Hernia- one dose preoperatively, can be pre and post operative or for 24hrs or even days.

49. 428 surgery team Thank You!