ACUTE SURGICAL ACUTE SURGICAL INFECTION INFECTION DR.A.KENSARAHDR.A.KENSARAH

ACUTE SURGICAL ACUTE SURGICAL INFECTIONINFECTION

Non-Specific Acute Infection Non-Specific Acute Infection Specific Acute Infection Specific Acute Infection

Non-Specific Acute Non-Specific Acute InfectionInfection

Postoperative Wound Infection Postoperative Wound Infection Cellulitis Cellulitis Erysipelas Erysipelas Boil (Furuncle) Boil (Furuncle) Carbuncle Carbuncle Hydradenitis Suppurativa Hydradenitis Suppurativa Acute Abscess Acute Abscess Acute Lymphangitis and Lymphadenitis Acute Lymphangitis and Lymphadenitis Bacteraemia and SepticaemiaBacteraemia and Septicaemia

Specific Acute Specific Acute InfectionsInfections Tetanus Tetanus

Gas Gangrene Gas Gangrene

Necrotizing Fasciitis Necrotizing Fasciitis

PPostoperative ostoperative WWound ound IInfectionsnfections

Are caused by the presence of Are caused by the presence of contaminating microbes derived from : contaminating microbes derived from :

EndogenousEndogenous

OR OR

ExogenousExogenous

Postoperative Wound Postoperative Wound InfectionInfection

Predisposing Factors: Predisposing Factors: # General# General

1-1- Poor general condition Poor general condition

2-2- Systemic disease Systemic disease

3-3- Drugs that cause Drugs that cause immunosuppressionimmunosuppression

Postoperative Wound Postoperative Wound InfectionInfection

# Local# Local ::

1-1- Poor blood supply Poor blood supply 2-2- Poor surgical technique Poor surgical technique 3-3- Presence of foreign bodies Presence of foreign bodies 4-4- Nature of the operation Nature of the operation 5-5- Defect in Defect in sterilization technique insterilization technique in

the operating theatrethe operating theatre

TTypes of ypes of ssurgical urgical wwoundsounds

Operative wounds are divided into Operative wounds are divided into three three categories :categories : 1-1- Clean The risk of Clean The risk of infection is infection is 1-2%1-2% 2-2- Clean Clean contaminated The risk of infection contaminated The risk of infection 2-5%2-5% 3-3- Contaminated The risk of infection Contaminated The risk of infection is is 5-30%5-30%

PPathologyathology

AcuteAcute inflammatory stage with inflammatory stage with local local vasodilatation and vasodilatation and infiltration by infiltration by polymorph nuclear polymorph nuclear leucocytesleucocytes. This is . This is followed by suppuration with followed by suppuration with purulentpurulent discharge discharge

CClinical linical PPictureicture

Wound infection usually appears between Wound infection usually appears between the the fifthfifth and and tenthtenth days postoperative days postoperative

** Fever Fever ** Pain in the wound Pain in the wound Signs:Signs: __ swollen swollen __tenderness tenderness __redness redness __fluctuantfluctuant

DDifferential ifferential DDiagnosisiagnosis

Other causes of postoperative feverOther causes of postoperative fever

- chest infection chest infection - DVT DVT

- UTI UTI

Other causes of wound swelling Other causes of wound swelling

- heamatoma heamatoma

ProphylaxisProphylaxis

** Improve the defense mechanism Improve the defense mechanism

** Control the predisposing factors Control the predisposing factors ** Prophylactic antibiotics Prophylactic antibiotics ** In bowel surgery, mechanical In bowel surgery, mechanical and chemical preparation of the boweland chemical preparation of the bowel

** Meticulous surgery Meticulous surgery ** Operation in septic areas with Operation in septic areas with heavily contaminated wounds should heavily contaminated wounds should be left be left openopen

TTreatmentreatment

Surgical drainage of the pus Surgical drainage of the pus Antibiotics in invasive infectionsAntibiotics in invasive infections Look for hospital acquired Look for hospital acquired

infectioninfection

CCellulitisellulitis

Is an Is an invasiveinvasive non suppurative non suppurative infection of the loose connective infection of the loose connective tissuetissue

Organism :Organism : streptococci [common]streptococci [common] staphylococci [occasionally] staphylococci [occasionally]

mixmix

CClinical linical ppictureicture

The affected area is red,indurated,hot and The affected area is red,indurated,hot and painfulpainful

It spreads rapidly with ill defined edgeIt spreads rapidly with ill defined edge The skin may be the seat of blistersThe skin may be the seat of blisters FeverFever Lymphangitis in the form of red streaksLymphangitis in the form of red streaks No suppurationNo suppuration In severe cases patches of skin necrosis In severe cases patches of skin necrosis

with sloughing of subcutaneous tissueswith sloughing of subcutaneous tissues

DDifferetial ifferetial DDiagnosisiagnosis

Contact allergyContact allergy

Chemical inflammationChemical inflammation

DVTDVT

TTreatmentreatment

Rest and elevation of the affected Rest and elevation of the affected partpart

Antibiotic penicillin iv Antibiotic penicillin iv

EErysipelasrysipelas

Is a Is a rapidlyrapidly spreading non- spreading non-suppurative suppurative

inflammation of the inflammation of the lymphaticslymphatics of of the the

skin caused by a skin caused by a specific strainspecific strain of of

hemolytic streptococcihemolytic streptococci

CClinical linical PPictureicture

ToxemiaToxemia Locally : similar to cellulitis,but there Locally : similar to cellulitis,but there

are the following are the following differencesdifferences: :

1.1. The color of the skin is rose-pink The color of the skin is rose-pink

2.2. The edge is well defined The edge is well defined

3.3. There may islets of inflammation There may islets of inflammation

beyond the spreading marginbeyond the spreading margin

CComplicationsomplications

1.1. Facial erysipelas may lead to Facial erysipelas may lead to cavernous sinus thrombosiscavernous sinus thrombosis

2.2. Septicemia Septicemia

3.3. Recurrent erysipelas may block Recurrent erysipelas may block the lymphatics leading to the lymphatics leading to elephantiasis.elephantiasis.

TTreatmentreatment

IsolationIsolation

Similar to cellulitisSimilar to cellulitis

BBoil oil [[FuruncleFuruncle]]

Is a Is a staphylococcalstaphylococcal infection of a infection of a hair follicle or a sebaceous gland. hair follicle or a sebaceous gland.

The common sites:The common sites:

face, neck and axilla.face, neck and axilla.

Common in diabetics.Common in diabetics.

CClinical linical PPictureicture

A small painful indurated swelling A small painful indurated swelling which which is is

- red - red

- hot - hot

- and very tender- and very tender

TTreatmentreatment

1.1.Antibiotics. Antibiotics.

2.2.Antiseptic. Antiseptic.

CCarbunclearbuncle

Is infective gangrene of the Is infective gangrene of the subcutaneous tissues usually subcutaneous tissues usually secondary to infection by secondary to infection by Staphylococcus aureus.Staphylococcus aureus.

It is common in immunocompromised It is common in immunocompromised patients as in diabetics.patients as in diabetics.

The common sites:The common sites:

face, nape of the neck, and the backface, nape of the neck, and the back

PPathologyathology

Infection usually starts in a hair follicleInfection usually starts in a hair follicle Extends to the subcutaneous fat where Extends to the subcutaneous fat where

other hair follicles get the infection.other hair follicles get the infection. Multiple areas of necrosis and Multiple areas of necrosis and

thrombosis of blood vessels occur.thrombosis of blood vessels occur. Patches of skin undergo sloughing and Patches of skin undergo sloughing and

separate from the underlying separate from the underlying granulation tissuegranulation tissue

CClinical linical PPictureicture

There is usually sever toxemia.There is usually sever toxemia. Starts as a painful induration of Starts as a painful induration of

the skin and subcutaneous tissues.the skin and subcutaneous tissues. The skin is red.The skin is red. Swelling its central part becomes Swelling its central part becomes

soft.soft. Multiple areas of skin thin out and Multiple areas of skin thin out and

separate forming multiple sinuses.separate forming multiple sinuses.

CComplicationsomplications

Local spread of infection.Local spread of infection.

Pyaemia and septicemia.Pyaemia and septicemia.

Cavernous sinus thrombosisCavernous sinus thrombosis

Epidural abscess or meningitisEpidural abscess or meningitis

TTreatmentreatment

1.1.Antibiotics. Antibiotics.

2.2.culture and sensitivity of the discharge.culture and sensitivity of the discharge.

3.3.control of diabetes.control of diabetes.

4.4.surgical excision of sloughs.surgical excision of sloughs.

HHydradenitis ydradenitis SSuppurativauppurativa

Mixed staph. And streptococcal Mixed staph. And streptococcal infection infection

of the of the apocrineapocrine sweat glands, in the sweat glands, in the

perineumperineum or the or the axilla axilla,produces ,produces multiple multiple

abscesses and pus discharging abscesses and pus discharging sinuses.sinuses.

TTreatmentreatment

Surgical drainage of abscesses.Surgical drainage of abscesses.

Antiseptic and antifungal Antiseptic and antifungal applications.applications.

Surgical excision of the apocrine Surgical excision of the apocrine sweat-bearing skin following by skin sweat-bearing skin following by skin grafting is essential.grafting is essential.

AAcute cute AAbscessbscess

It is a localized suppurative It is a localized suppurative inflammation.inflammation.

It is caused by pyogenic It is caused by pyogenic organisms. The organisms. The commonest are staphylococci commonest are staphylococci that produce a coagulase that produce a coagulase enzyme.enzyme.

PPathogenesisathogenesis

The organism reach the tissues by :The organism reach the tissues by :

- - direct access through wounds, scratches direct access through wounds, scratches and abrasions. and abrasions.

- - local extension from an adjacent focus local extension from an adjacent focus

-- lymphatic spread. lymphatic spread.

-- blood spread. blood spread.

PPathologyathology

An abscess consists of An abscess consists of threethree zones: zones:

1-1- A A centralcentral zone of coagulative necrosis zone of coagulative necrosis

2-2- An An intermediateintermediate zone of granulation tissue. zone of granulation tissue.

3-3- A A peripheralperipheral zone of acute inflammation. zone of acute inflammation.

SSequleaequlea

Resolution.Resolution.

Pointing and rupture.Pointing and rupture.

Spread infection Spread infection –– locally locally

-- by lymphatics or blood by lymphatics or blood Chronicity.Chronicity.

CClinical linical PPictureicture

Locally :Locally :-- painful tender mass painful tender mass --The covering skin is red, and The covering skin is red, and oedematous oedematous --The draining lymph The draining lymph nodes are usually enlarged and nodes are usually enlarged and tender tender

Systemic :Systemic :--Fever Fever --Malaise Malaise --Headache Headache --Tachycardia Tachycardia --AnorexiaAnorexia

WWhen hen PPus us FFormsorms

The fever The fever becomes hectic.becomes hectic.

Skin shows Skin shows pitting oedema.pitting oedema.

The pain The pain becomes becomes throbbing.throbbing.

The inflamatory The inflamatory reaction becomes reaction becomes localizedlocalized

Fluctuation test Fluctuation test becomes positive.becomes positive.

There is shooting There is shooting leucocytosisleucocytosis

TTreatment reatment

Before suppurationBefore suppuration:: - antibiotic, rest -hot application. - antibiotic, rest -hot application. -supportive general -supportive general measures.measures.

After suppuration:After suppuration: -adequate surgical drainage. -adequate surgical drainage. -a specimen of the pus is sent for -a specimen of the pus is sent for culture and sensitivity. culture and sensitivity. -antibiotic if there is systemic -antibiotic if there is systemic manifestation. manifestation.

AAcute cute LLymphangitis ymphangitis aand nd LLyphadenitisyphadenitis Acute lymphangitis:is due to Acute lymphangitis:is due to

infection of lymph vessels by infection of lymph vessels by organisms usually organisms usually streptococcistreptococci..

Acute lymphadenitis: is due to Acute lymphadenitis: is due to spread of infection along spread of infection along lymphatics from a septic focus in lymphatics from a septic focus in the drainage area to the lymph- the drainage area to the lymph- nodes.nodes.

TTreatment reatment

Antibiotics.Antibiotics.

Hot applications.Hot applications.

Surgical drainage if suppuration Surgical drainage if suppuration occurs.occurs.

BBacteraemia acteraemia

Presence of bacteria which are Presence of bacteria which are NOT NOT multiplyingmultiplying, in the blood., in the blood.

It usually follows:It usually follows: - dental work. - dental work. -instrumentation of the urinary -instrumentation of the urinary tracttract

It is It is hazardoushazardous in patients with : in patients with : -damaged heart valves. -damaged heart valves. -prosthetic valves. -prosthetic valves. -immunosuppression -immunosuppression

Prophylactic antibiotics is Prophylactic antibiotics is essentialessential

SepticemiaSepticemia

The presence of The presence of multiplyingmultiplying organisms organisms

in the blood stream.in the blood stream.

Specific Acute InfectionsSpecific Acute Infections

TTetanus etanus

It is a specific anaerobic infection It is a specific anaerobic infection that is mediated by that is mediated by neurotoxinneurotoxin of: of:

Clostridium tetaniClostridium tetani

and leads to:and leads to:

nervous irritability and tetanic nervous irritability and tetanic muscular contractions.muscular contractions.

AAetiology etiology

Organism: Organism: Clostridiuam tetaniClostridiuam tetani is is

gram positive anaerobic bacillusgram positive anaerobic bacillus with a with a

terminalterminal spore giving the spore giving the characteristic characteristic

drum-stickdrum-stick appearance. appearance.

MMode ode OOf f IInfectionnfection

1.1. Wounds:-hypoxic,containing Wounds:-hypoxic,containing devaitalized tissue or a foreign devaitalized tissue or a foreign body.body.

2.2.Umbilical stump: tetanus Umbilical stump: tetanus neonatorumneonatorum

PPathology athology

The neurotoxin is an The neurotoxin is an exotoxin exotoxin produced produced locallylocally and reaches the central nervous and reaches the central nervous system along the system along the bloodblood streamstream, the , the motor nervesmotor nerves or or bothboth..

When the toxin reaches the nervous When the toxin reaches the nervous system, it is system, it is fixedfixed by the motor cells and by the motor cells and can notcan not be detected in the blood or CSF. be detected in the blood or CSF.

The The antitoxin antitoxin can can onlyonly neutralize the neutralize the toxin before it gets fixed to the nervous toxin before it gets fixed to the nervous tissue.tissue.

The toxin The toxin increasesincreases the exitability the exitability of the motor cells of the medulla of the motor cells of the medulla and spinal cord, so slightest and spinal cord, so slightest stimuli produce violent spasm.stimuli produce violent spasm.

DeathDeath results from exhaustion, results from exhaustion, hyperpyrexia, heart failure, hyperpyrexia, heart failure, asphyxia or pneumonia. asphyxia or pneumonia.

CClinical linical PPictureicture

Incubation period:Incubation period: - In non-immunized is short from 24H - In non-immunized is short from 24H to 15 days. to 15 days. - In immunized is longer than 11 - In immunized is longer than 11 days to several weeks or months.days to several weeks or months.

Symptoms during incubation period are Symptoms during incubation period are vague such as :vague such as : tenderness, rigidity of tenderness, rigidity of the muscles, swelling at the site of the muscles, swelling at the site of wound, local twitches, restlessness, and wound, local twitches, restlessness, and an anxiety. an anxiety.

Tonic stage:Tonic stage: -Pain and tingling in the area of -Pain and tingling in the area of injury. -Limitation of movements injury. -Limitation of movements of the jaw. -Spasm of the facial of the jaw. -Spasm of the facial muscles. -Stiffness of muscles. -Stiffness of the neck. -the neck. -Dysphagia. Dysphagia. -Laryngospasm. -Laryngospasm. -Hesitancy in micturition. -Hesitancy in micturition.

Clonic stage:Clonic stage: -Reflex paroxysms of violent -Reflex paroxysms of violent muscular contraction. muscular contraction. -Relaxation is incomplete -Relaxation is incomplete during the intervals between clonic during the intervals between clonic contractions. -Spasm of the contractions. -Spasm of the intercostal muscles and diaphragm lead intercostal muscles and diaphragm lead to long period of apnea. -Temperature to long period of apnea. -Temperature elevated with profuse sweating. elevated with profuse sweating. -Marked -Marked tachycardia tachycardia

LLaboratory aboratory FFindinginding

Polymorphnuclear leucocytosis.Polymorphnuclear leucocytosis.

PPrevention revention

Immunization [Immunization [activeactive] with tetanus toxoid ] with tetanus toxoid with routine childhood immunization, with with routine childhood immunization, with booster injections every booster injections every 7-10 years7-10 years..

Individuals who previously received three Individuals who previously received three or more doses, the last within 10 years: or more doses, the last within 10 years: need a booster dose of tetanus toxoid.need a booster dose of tetanus toxoid.

Those who received less than three doses: Those who received less than three doses: -need a booster dose of tetanus toxoid -need a booster dose of tetanus toxoid and tetanus immunoglobulin [and tetanus immunoglobulin [passivepassive].].

Individuals Individuals notnot previously immunized: previously immunized: -need full immunization with -need full immunization with tetanus toxoid and tetanus tetanus toxoid and tetanus immunoglobulin.immunoglobulin.

TTreatment reatment

Neutralize toxin with TIG.Neutralize toxin with TIG. Wound debridment.Wound debridment. Avoid sudden stimuli.Avoid sudden stimuli. Muscle relaxant with mechanical Muscle relaxant with mechanical

ventilation may require tracheostomy.ventilation may require tracheostomy. Aqueous penicillin G ,10-40 million Aqueous penicillin G ,10-40 million

units a day IV.units a day IV. Nursing.Nursing.

GGas as GGangreneangrene

It is an It is an acuteacute spreading infection spreading infection

associated with gas formation and associated with gas formation and

profound toxaemia caused by profound toxaemia caused by anaerobicanaerobic

spore-bearing bacillispore-bearing bacilli of the of the clostridiumclostridium

group.group.

PPathology athology

Clostridia proliferate and produce Clostridia proliferate and produce toxins that diffuse into the toxins that diffuse into the surrounding tissue.surrounding tissue.

The toxins destroy local circulation.The toxins destroy local circulation.

This allows further invasion.This allows further invasion.

Factors predisposing Factors predisposing to gas gangrene:to gas gangrene: Lacerated wounds involving bulky Lacerated wounds involving bulky

muscles.muscles. Presence of foreign bodies or Presence of foreign bodies or

devitalized tissues.devitalized tissues. Ischemia of muscles.Ischemia of muscles. Infection by anaerobic bacteria.Infection by anaerobic bacteria. As a complication of above knee As a complication of above knee

amputation in patient with faecal amputation in patient with faecal incontinence.incontinence.

BBacteriology acteriology

Organisms falls into Organisms falls into twotwo groups: groups: Saccharolytic organisms:Saccharolytic organisms:

-Cl.welchii,-Cl.septicum,- -Cl.welchii,-Cl.septicum,-and and Cl.oedematiensCl.oedematiens

Proteolytic organisms:Proteolytic organisms: -Cl.sporogenes,- -Cl.sporogenes,-Cl.histolyticum and Cl.tertium.Cl.histolyticum and Cl.tertium.

CClinical linical PPictureicture

The incubation period varies from few The incubation period varies from few hours to few days.hours to few days.

GenerallyGenerally ;the patient is pale, anxious, ;the patient is pale, anxious, and apprehensive. and apprehensive. -The temperature may be raised -The temperature may be raised and there is marked tachycardia. and there is marked tachycardia. -The hands are cold and clammy. -The hands are cold and clammy. -An icteric tinge may be present -An icteric tinge may be present and there is oliguria.In severe case there and there is oliguria.In severe case there is shock. is shock.

Locally:Locally: -pain and numbness in the -pain and numbness in the affected area. affected area. -swelling and there may be crepitus -swelling and there may be crepitus with gas bubbles. with gas bubbles. -A sanguineous dischrge of a -A sanguineous dischrge of a characteristic odour. characteristic odour. -The affected muscles -The affected muscles brick redbrick red then then greenishgreenish and finally and finally blackblack discolouration,do not contract,do discolouration,do not contract,do not bleed if cut, the skin black. not bleed if cut, the skin black.

PPrevention revention

Adequate debridement of Adequate debridement of wounds.wounds.

Antibiotics.Antibiotics.

Avoid tissue hypoxia.Avoid tissue hypoxia.

TTreatment reatment

Wound management.Wound management.

Hyperbaric oxygenation.Hyperbaric oxygenation.

Antibiotics: penecillin.Antibiotics: penecillin.

NNecrotizing ecrotizing FFasciitisasciitis

It is an invasive infection usually It is an invasive infection usually caused by a caused by a mixedmixed microbial flora microbial flora including microphilic streptococci, including microphilic streptococci, staphylococci, Gram-negative staphylococci, Gram-negative bacteria and anaerobes,especially bacteria and anaerobes,especially peptostreptococci, and peptostreptococci, and bacteroids. bacteroids.

PPathology athology

The infectious process spreads along The infectious process spreads along the fascial planes and results the fascial planes and results infectious thrombosis of the vessels infectious thrombosis of the vessels passing between the skin and deep passing between the skin and deep circulation.circulation.

Superficial skin necrosis follows.Superficial skin necrosis follows. Hemorrhagic bullae appear as the first Hemorrhagic bullae appear as the first

sign of skin death.sign of skin death. Fascial and subcutaneous fat necrosis Fascial and subcutaneous fat necrosis

involves wider area than the skin.involves wider area than the skin.

CClinical linical PPictureicture

There are manifestations of There are manifestations of toxemia with fever and toxemia with fever and tachycardia.tachycardia.

The skin shows hemorrhagic The skin shows hemorrhagic bullae and necrosis surrounded bullae and necrosis surrounded by oedema and inflammation.by oedema and inflammation.

Crepitus is occasionally present.Crepitus is occasionally present.

IInvestigations nvestigations

Swab for culture and sensitivity Swab for culture and sensitivity

At surgery :oedematous, dull gray At surgery :oedematous, dull gray fascia and subcutaneous tissue fascia and subcutaneous tissue with visible thrombi in with visible thrombi in penetrating vessels penetrating vessels

PPreventionrevention

Adequate debridement of woundsAdequate debridement of wounds

Antibiotics Antibiotics

TTreatment reatment

SurgicalSurgical

AntibioticsAntibiotics

Blood transfusionBlood transfusion