SURGICAL INFECTION & ANTIBIOTIC POLICY

SURGICAL INFECTION &ANTIBIOTIC POLICYQURAISHIA ALYANURUL SYAZWANIALYA MAZLANAZRIAHNAZIFANAIMSHAHRIMAN

1Outline Of SeminarSurgical site infection Post operation wound healingAcute surgical infectionCarbuncleNecrotizing fasciitisInfected cystClassification of surgical woundsAntibiotic policyOverviewEtiology and pathogenesis of surgical infectionEtiology and pathogenesis of post operative wound healingWound HealingInvolves 3 overlapping major phases:Inflammation, with cascades of processes that can be further subdivided into early and late phases.RegenerationMaturationThe key cells that are involved in this process:Inflammation: platelets, neutrophils, lymphocytes and macrophagesRegeneration and maturation: macrophages and fibroblasts (myofibroblasts)Inflammation:Early inflammation (first 24 hours) begins with haemostasis through vasoconstriction, thrombin formation and platelet aggregation. Platelets release cytokines and other factors that influence leucocyte and monocyte activity.Late inflammation(24-72 hours) release of vasodilators that increase permeability of local capillary bed for serum and white cells to be released to surround the wound in margination and diapedesis.

RegenerationFollows over next few days . Characterized by increase in fibroblast mitogenic activity and endothelial cell mitotic activity , with epithelial cell migration and synthesis of collagen and metalloproteinases.

Maturation (remodelling phase)Can take up to 2 years. Granulation tissue gradually matures into scar tissue. Fibroblasts and proteases maintain balance between deposition and degradation of tissue.

Infection is usually prevented by natural mechanism ; eg: mechanical barriers (skin), chemical (low gastric pH), humoral (antibodies), cellular (phagocytic cells).May be compromised by surgical intervention and treatment.Causes of reduced resistance to infection:Metabolic : malnutrition, diabetes, uraemia, jaundiceDisseminated disease: cancer, AIDSIatrogenic: radiotherapy, chemotherapy, steroids.Risk factors for increased risk of wound infectionMalnutrition (obesity, weight loss)Metabolic disease ( diabetes, uraemis, jaundice)Immunosuppression ( cancer, AIDS)Colonisation and translocation in GITPoor perfusion (systemic shock, local ischemia)Foreign body materialPoor surgical technique (dead space, hematoma)Surgical Site Infection (SSI)Infection that occur in the wound created by an invasive surgical procedure.Many of these infections occur after the patient has been discharged from hospital.Types:Incisional Superficial (skin and cutaneous tissue)Deep (fascial and muscles)Organ space eg: intra-abdominal abscess

ETIOLOGYClassification of sources of infection Primary: present in or on the host and so acquired from an endogenous source (eg: contamination of wound from a perforated appendix)Secondary or exogenous: acquired from a source outside the body (eg: operating theatre-inadequate air filtration, poor asepsis / the ward- poor hand washing compliance)Microbial factorMost SSI are contaminated by patients own endogenous flora (on skin, mucous membranes, or hollow viscera)Bacteria involved:Gram positive cocci :Streptococci - Streptococci pyogenesStaphylococci Staphylococcus aureusGram negative bacilliE. coli, Klebsiella spp.ClostridiaBacteroidesPathogenesisDevelopment of SSI depends on contamination of wound site at the end of surgical procedure and specifically relates to pathogenicity and inoculum of microorganisms present, balanced against the hosts immune response.ReferenceBailey & Love Short practice of surgery (26th Edition)NICE Clinical Guideline 2008 (Surgical site infection prevention and treatment of surgical site infection) https://www.nice.org.uk/guidance/cg74/evidence/cg74-surgical-site-infection-full-guideline2

http://emedicine.medscape.com/article/188988-treatment

SURGICAL SITE INFECTIONS-TYPES, PRESENTATIONS COMPLICATIONS, & TREATMENT

BY: NURUL SYAZWANI MOHD THANI012012050564

PRESENTATIONS

Superficial incisional SSI may produce pus, or purulent discharge from the wound site along with atleast one sign of inflammation (pain, redness, swelling, local warmth of wound,etc)Deep incisional SSI puulent discharge may present but without organ/ space involvement. The wound site may reopen on its own, or a surgeon may reopen the wound and find purulent discharge inside the wound.BASED ON SITE OF INFECTIONSCONTOrgan or space SSI may show a discharge of pus coming from a drain placed through the skin into a body space or organ. A collection of purulent discharge may lead to an abscess (occur within 30 days of operation)

MAJOR AND MINOR SURGICAL SITE INFECTIONSMajor wound infections:Significant quantity of pusPatients are systemically ill (may have systemic signs such as tachycardia, pyrexia and raised in white cell count)Minor wound infections:Small quantity pus but NOT associated with excessive discomfort or any systemic signs

CONTOther than pus or abscess, patient with SSI may present with:Cellulitis and lymphangitisBacteremia and sepsisGas gangrene

COMPLICATIONS OF WOUND HEALING

1. infection2. Ugly scar3. Keloid & hypertrophic scar4. Incisional hernia & wound dehiscence5. Pigmentation of the skin6. Marjolins ulcer

TREATMENTSuture removal plus incision and drainage should be performed for SSIs (to allow pus to drain adequately)Major surgical infections with systemic signs need treatment with appropriate antibioticsMinor infections may respond to drainage of pus (for example, by removal of sutures) and topical antisepsisThe choice of antibiotics is empirical until sensitivities are availableEmpirical therapy should be broad-spectrum and cover S. aureus, which is the most common cause of SSI after all types of operation

SSIs after clean-contaminated surgery should be treated with an empirical antibiotic regimen that includes activity against anaerobic bacteria (eg: metronidazole, co-amoxiclav, piperacillin-tazobactam or meropenem).SSIs in patients known to have, or at risk of methicillin-resistant S. aureus (MRSA) carriage should be treated with an empirical antibiotic regimen that includes activity against locally prevalent strains of MRSA (eg: first-generation Cephalosporins, vancomycin and antistaphylococcalpenicillins such as nafcillin, oxacillin)referencesBailey & Love Short practice of surgery (26th Edition)Manipal Manual of Surgery (4th Edition)

https://www.nice.org.uk/guidance/cg74/evidence/cg74-surgical-site-infection-full-guideline2

http://emedicine.medscape.com/article/188988-treatment

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Acute Surgical Infection (cont.)NUR AZRIAH BINTI KAMARZAMAN012013100256OUTLINEClinical featuresComplication/ Risk factorTreatment

CELLULITISCLINICAL FEATURESThe affected area is red,indurated,hot and painfulIt spreads rapidly with ill defined edgeThe skin may be the seat of blistersFeverLymphangitis in the form of red streaksNo suppurationIn severe cases patches of skin necrosis with sloughing of subcutaneous tissues

COMPLICATIONSepticaemiaAbscessNecrotising fasciitismeningititsTREATMENTGram positive cover. Used broad spectrum for immune compromised/ diabetic patientCephalosporins (cephalothin, cephalexin) for antistaphylococcal coverage except for MRSA

FURUNCLE (BOIL)CLINICAL FEATURESSwelling which is raised, red,with discharging pus through one punctum with central filling of necrotic tissue. site of friction, occlusion, and perspiration (neck, axilla, buttocks)Tender, hot swelling, non-mobileFirm at first then become fluctuant

COMPLICATIONCavernous sinus thrombosisSystemic sepsis in uncontrolled diabetes

TREATMENTHeal spontaneouslySome cased incision and drainage needed (done under local anaesthesia)Remove necrotic centre/slough and continue drassings till heals completelyControl of diabetes if presentCARBUNCLECLINICAL FEATURESTypically in diabetic patientSevere pain and swelling in the nape of the neckConstitutional symptoms such as fever with chills and rigors are severeSurface is red, angry looking like red hot coalSurrounding area is induratedLater, skin on the centre of carbuncle softens and peripheral satellite vesicles appear, which rupture discharging pus and giving rise to a cribriform appearanceThe end result Is development of large crateriform ulcer with central sloughCOMPLICATIONWorsening of the diabetic status resulting in diabetic ketoacidosisExtensive necrosis of skin overlying carbuncle. Hence, it is included under acute infective gangreneSepticaemia, toxaemiaTREATMENTDiabetic control, preferably with injected insulinAppropriate parenteral antibiotics are given till complete resolution occurImprove general health of the patientIf carbuncle does not show any evidence of healingNot incisedLeft open to exterior or saline dressings may be applied to reduce oedema complete resolution within 10-15 daysSurgery required when there is pusCruciate incision is preferredSEBACEOUS CYSTCLINICAL FEATURESSingle/multipleSite: can be anywhere except palm and sole. Common site: scalp, neck, axilla, groin, scrotumSize: 5mm-2cmShape: sphericalSmooth surface with well defined marginConsistency: firmSkin: usually normal but when infected may cause redden skin and tender/ increase temperature on palpationAssociated features: punctum where foul-smelling cheesy exudates (sebum) can be squeezed out/ sebaceous hornNot comprissible/reducibleCOMPLICATIONSInfectionUlcerationRupture and sinus formationCalcificationCocks peculiar tumorSebaceous hornTREATMENTRemoval of entire cyst wall together with the punctum by ecliptical incision to prevent recurrenceIntralesional steroid at 5mg/m to control small inflamed symptomatic lesionIf cyst is infected- incision and drainagewith antibiotic to cover S.aureusIf cyst ruptured/ infected- drainage and curatage doneNECROTISING FASCIITISCLINICAL FEATURESSudden pain in the affected area with gross swelling of the limbsThe part is swollen, red, erythematous and oedematous with skip lesion of skin necrosis and ulcerationSkin changes: bronze hue, brawny induration, blebs or crepitus High degree fever, jaundice, renal failure can occur soon in untreated casesRISK FACTORDiabetes mellitus,MalnutritionObesityCorticosteroidImmune deficiencyTREATMENTMedical emergencySupportive treatmentHospitalizationAdequate hydrationBroad spectrum antibiotics vancomycin + carbapenemIn type ll cases (streptococcal) : high dose penicillin + clindamycin Surgical treatmentInvolves wide excision, generous debridement followed by skin grfating, a few days or weeks later

Classification of Surgical WoundsNazifa Nusral012012050561CleanClean-contaminatedContaminatedDirty Uninfected operative wound.No inflammation.Respiratory, alimentary, genital, or uninfected urinary tract is not entered.No viscus opened.Primarily closed, if necessary, drained with closed drainage.1-2 % infection rate.Rate before prophylaxis is the same.Eg: Breast biopsy.Clean woundAn operative wound where respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination.Viscus opened, minimal spillage.