SURGERY

I Dr. E. Lahoz 1

SURGICAL INFECTIONS

BARRIERS OF INFECTION (FIRST LINE OF DEFENSE)
1. Physical barrier- epithelial/mucosa
2. Host barrier cells- substances secreted
limits microbial proliferation
prevents invasion
3. Resident/commensal microbes (good
bacteria)

Principal Hormonal Responses to Surgical Stress
ENDOCRINE
HORMONES
CHANGE IN
GLAND
SECRETION
Anterior
Corticotropin
Increased
Pituitary
Growth
Increased
Hormone
Thyrotropin
Variable
FSH, LH
Variable
Posterior
Arginine
Increased
Pituitary
Vasopressin
Adrenal cortex
Cortisol
Increased
Aldosterone
Increased
Pancreas
Insulin
Decreased
Glucagon
Increased
Thyroid
Thyroxine
Decreased
Triiodothyronine
Decreased

OUTCOME
1. Eradication
2. Containment
3. Locoregional infection
4. Systemic

DIAGNOSTIC CRITERIA FOR SEPSIS
st

(PCS, Handbook of Critical Care & Surgical Nutrition, 1 edition, 2015)

INFECTION, documented or suspected and some of
the following:

GENERAL VARIABLES
- fever- >38.3 C
- Hypothermia (core temperature < 36 C)
- HR >90/min or more than 2 SD above the
normal value for age
- Tachypnea
- Altered mental status
- Significant edema or positive fluid balance
(>20 ml/kg over 24 hours)
- Hyperglycemia (plasma glucose >140 mg/dl
or 77 mmol/mL) in the absence of diabetes

INFLAMMATORY VARIABLES
- Leukocytosis (WBC >12,000 uL-1)
- Leukopenia (WBC <4,000 uL-1)
- Normal WBC with >10% immature forms
- Plasma C-reactive protein more than 2 SD
above the normal value

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Plasma procalcitonin more than 2 SD above

the normal value

HEMODYNAMIC VARIABLES
- arterial HPN (SBP <90 mmHg, MAP <70
mmHg, or an SBP decrease >40 mmHg in
adults or less than 2 SD below normal for
age)

ORGAN DYSFUNCTION VARIABLES

- Arterial hypoxemia (PaO2/FiO2 <800)
- Acute oliguria (UO <0.5 ml/kg/hr for at least
2 hours despite adequate fluid
resuscitation)
- Creatinine increase >0.5 mg/dl or 44.2
umol/L
- Coagulation abnormalities (INR >1.5
or
a PTT >60 sesc)
- Ileus (absent bowel sound)
- Thrombocytopenia (Plt count <100,000 uL)
- Hyperbilirubinemia (total plasma bilirubin
>4 mg/dl or 70 umol/L)

TOTAL PERFUSION VARIABLES
- Hyperlactatemia (>1 mmol/L)
- Decreased capillary refill or mottling

SEVERE SEPSIS
- sepsis induced tissue hypoperfusion or organ
dysfunction (any of the following thought to
be due to infection)
o Sepsis induced hypotension
o Lactate above upper limits of normal
laboratory values
o Urine output <0.5 ml/kg/hr for more
than 2 hours despite adequate fluid
resuscitation
o Acute lung injury with PaO2/FiO2 <250
in the absence of Pneumonia as
infection source
o Acute lung injury with PaO2/FiO2 <200
in the presence of Pneumonia as
infection source
o Creatinine >2.0 mg/dl (176 umol/L)
o Bilirubin >2 mg/dl (34.2 umol/L)
o Platelet count <100,00 uL
o Coagulopathy (International normalized
ratio >1.5)

SURGERY I Dr. E. Lahoz 3

GENERAL PRINCIPLES IN MANAGEMENT
1. Reduce presence of exogenous and endogenous
microorganisms (prophylaxis):
Mechanical
Chemical
Antimicrobial agent
2. Source Control
Drainage
Debridement
Removal of foreign body

PATHOGEN SOURCES
1. ENDOGENOUS
Patient flora
- skin
- mucous membranes
- GI tract
Seeding from a distant focus of
infection

2. EXOGENOUS
Surgical Personnel (surgeon and team)
- soiled attire
- breaks in aseptic technique
- inadequate hand hygiene
OR physical environment and
ventilation
Tools, equipment, materials brought to
the operative field

FACTORS INFLUENCING ANTIBIOTIC CHOICE

1. Activity against known/suspected
pathogens
2. Disease believed responsible
3. Distinguish infection from colonization
4. Narrow-spectrum coverage most desirable
5. Antimicrobial resistance patterns
6. Patient-specific factors
a. Severity of illness
b. Age (?)
c. Immunosuppression
d. Organ dysfunction
e. Allergy
7. Institutional guidelines/restrictions

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DURATION OF TREATMENT
Prophylaxis- single dose
Empiric- 3-5 days (discontinue absence of
local or systemic infection)
Therapeutic- follow standard guidelines

SOURCE CONTROL
1. Identify specific anatomical diagnosis of
infection and intervention be undertaken
within first 12 hours, if feasible.
2. Infected peripancreatic necrosis identified-
delay intervention until adequate
demarcation in identified
3. Source control- intervention with least
physiologic insult
4. If intravenous devices as source- remove
after another access is established

OTHER CONSIDERATIONS
1. Mechanical ventilation for sepsis-induced
acute respiratory syndrome (ARDS)
2. Glucose control
3. Renal replacement therapy
4. Bicarbonate therapy
5. Deep vein thrombosis prophylaxis
6. Stress ulcer prophylaxis
7. Nutrition

SURGICAL SITE INFECTION

SUPERFICIAL INCISIONAL SSI

occurs within 30 days, and
involves only skin or subcutaneous tissue
and has at least one of the following:
- purulent discharge
- organism isolated
- at least one of the s/sx:
o pain or tenderness
o localized swelling
o redness or heat
o incision intentionally opened by
surgeon
o disease made by surgeon

NOT SSI
stitch abscess
infected episiotomy or newborn
circumcision site
infected burn wound
incisional SSI that extends into the fascial
and muscle layers

DEEP INCISIONAL SSI
Has at least one of the following:
- with 30 days to 1 year (if with
implant), and
- involves fascia or muscle of the
incision, and
- at least one of the following:
o purulent discharge from
deep incision
o dehiscence (spontaneous or
intentional) with at least
one (fever, localized pain or
tenderness)
o abscess or evidence of
infection in deep areas
o disease made by surgeon
ORGAN/SPACE SSI
within 30 days to 1 year (if with implant),
and
involves other parts of body exclusing skin,
fascia and muscle, and
purulent discharge from a drain
organisms isolated from fluid or tissue
abscess or evidence of infection
disease made by surgeon

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MEDICAL CONDITIONS KNOWN TO INCREASE RISK
OF POST-OPERATIVE INFECTION
1. Extremes of age (neonates, very old adults)
2. Malnutrition
3. Obesity
4. Diabetes mellitus
5. Prior site irradiation
6. Hypothermia
7. Hypoxemia
8. Coexisting infection remote to surgical site
9. Corticosteroid therapy
10. Recent operation, especially of chest or
abdomen
11. Chronic inflammation
12. Hypocholesterolemia

OPEN WOUND- healing by secondary intention

SURGICAL WOUND CLASSIFICATION

1. CLASS I/CLEAN
- an uninfected operative wound in which
no inflammation is encountered and the
respiratory, alimentary, genital or
uninfected urinary tract is not entered. In
addition, clean wounds are primarily
closed and, if necessary, drained with
closed drainage. Operative incisional
wounds that follow non-penetrating
(blunt) trauma should be included in this
category if they meet the criteria.

2. CLASS II/CLEAN-CONTAMINATED
- an operative wound in which the
respiratory, alimentary, genital or urinary
tracts are entered under controlled
conditions and without unusual
contamination. Specifically, operations
involving the biliary tract, appendix, vagina
and oropharynx are included in this
category, provided no evidence of
infection or major break in technique is
encountered.

3. CLASS III/CONTAMINATED
- open, fresh, accidental wounds. In
addition, operations with major breaks in
sterile technique (eg. open cardiac
massage) or gross spillage from the GIT
and incisions in which acute, nonpurulent
inflammation is encountered are included
in this category.

4. CLASS IV/DIRTY-INFECTED
- old traumatic wounds with retained
devitalized tissue and those that involve
existing clinical infection or perforated
viscera. This definition suggests that the
organisms causing postoperative infection
were present in the operative field before
the operation.

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1.

2.

3.

4.
5.
6.

7.

PREOPERATIVE PREVENTIVE MEASURES

Antimicrobial prophylaxis guidelines
a. Administer within 1 hour prior to incision
b. Select appropriate agents
- surgical procedure
- most common pathogen
- published recommendations
Treat remote infections whenever possible
a. Identify and treat prior to elective
operation
b. Postpone operation until infection has
resolved
Do not remove hair unless it is necessary
a. Remove by clipping or depilatory agent
b. Do not use razors
Skin preparation- use appropriate antiseptic
agent and technique for skin penetration.
Maintain post-op normothermia
Colorectal surgery
a. Mechanically prepare the colon
b. Administer non-absorbable oral
antimicrobial agent the day before
surgery
OR traffic
a. Keep OR doors closed except when
needed

PRINCIPLES IN AMP
1. Use AMP shown to reduce SSI
2. Use AMP- safe, inexpensive and
bactericidal that covers most probable
intra-op contaminants
3. Time of infusion- bactericidal concentration
achieved in serum and tissue when skin is
incised.
4. Maintain therapeutic level throughout the
operation and until, at most, few hours
after incision is closed.

INDICATIONS IN AMP
1. All operations that entail entry to hollow
viscus under controlled conditions.
2. Clean operation
a. Prosthetics is inserted
b. Incisional or organ/space SSI poses
catastrophic risk (cardiac, vascular,
neurosurgical, breast)
*not indicated for contaminated or
dirty operations therapeutic

PERIOPERATIVE SUPPLEMENTAL MEASURES
1. Redose antibiotic at 3 hours interval
2. Adjust antimicrobial prophylaxis in obese
patient
3. Use at least 50% fraction of inspired oxygen
intra-op and immediately post-op

ORGANISM CAUSING SSI (Jan 2006-Oct 2007, CDC)
1. Staphylococcus aureus- 30%
2. Coagulase-negative staphylococci- 13.7%
3. Enterococcus spp- 11.2%
4. Escherichia coli- 9.6%
5. Pseudomonas aeruginosa- 5.6%
6. Enterobacter spp.- 4.2%
7. Klebsiella pneumoniae- 3%
8. Candida spp.- 2%
9. Klebsiella oxytoca- 0.7%
10. Acinetobacter baumannii- 0.6%

INTRA-ABDOMINAL INFECTION
Must meet at least one of the following criteria:
1. Positive culture from intra-abdominal space
2. Patient has:
a. Abscess or other evidence or intra-
abdominal infection on gross
anatomic or histopathology exam
b. Organisms identified from blood
(contains one of the ff. org:
Bacteroides, Candida, Clostridium,
Enterococcus, Fusobacterium,

SURGERY I Dr. E. Lahoz 7

Peptostreptococcus, Prevotella,
Veillonella or Enterobacteriaceae
3. Patient has at least two of the following s/sx
(with no other recognized cause):
a. Fever
b. Nausea
c. Vomiting
d. Abdominal pain
e. Jaundice
f. And at least one of the ff:
- organisms on gram stain or
culture sensitivity (drainage)
- organisms identified in blood

INTRA-ABDOMINAL INFECTION
Peritonitis- microbial contamination of the
peritoneal cavity

CLASSIFICATION (ETIOLOGY)
1. Primary- hematogenous route from a
distant source or direct inoculation.
2. Secondary- subsequent contamination due
to perforation or severe inflammation and
infection of an intra-abdominal organ
3. Tertiary- persistent peritonitis

PRIMARY PERITONITIS
- hematogenous route form a distant source or
direct inoculation
- common in patient with ascites, undergoing
peritoneal dialysis
- rarely requires surgical intervention
- DX:
Diffuse tenderness and guarding
without localized findings
Absence of pneumoperitoneum
>100 WBCs/mL
GS: positive for micribes
- Usual org: E. coli, Klebsiella, Pneumococci
- TX
Antibiotic: 14-21 days
Removal of foreign bodies (tubes)

SECONDARY PERITONITIS
- subsequent contamination due to perforation
or severe inflammation and infection of an
intra-abdominal organ.

TX:
Source control
Resect or repair GIT
Debride necrotic tissue
Antibiotic: aerobes + anaerobes
Ileus- parenteral antibiotic

-

TERTIARY PERITONITIS
- persistent peritonitis (same result of failed
therapy intra-abdominal abscess and GIT
anastomotic leak)
- lack of responsiveness to the antibiotic
- TX:
Explore lap or percutaneous
drainage
Antibiotic: aerobes + anaerobes

SKIN AND SOFT TISSUE INFECTION

SKIN INFECTION
Must meet at least one of the following criteria:
1. Patient has at least one of the following:
Purulent drainage
Pustules
Vesicles
Boils (excluding acne)
2. Patient has at least two localized s/sx
Pain or tenderness
Swelling
Erythema
Heat
At least one of the ff:
- Organism isolated form aspirate
or drainage
- Multinucleated giant cells seen on
microscope of affected tissue
- Diagnostic single antibody titer
(IgM) or 4x increase of paired sera
(IgG)

SOFT TISSUE INFECTION
Must meet at least one of the following criteria:
1. Positive organism from tissue or drainage
2. Purulent discharge at affected site
3. Abscess or other evidence of infection

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CELLULITIS

NECROTIZING FASCIITIS

FOLLICULITIS

PRESSURE SORES

FURUNCLE

CARBUNCLE

HIDRADENITIS SUPPURATIVA

POST-OPERATIVE NOSOCOMIAL INFECTION

SURGERY I Dr. E. Lahoz 9

SURGICAL CARE IMPROVEMENT PROJECT
PERFORMANCE MEASURES
1. ANTIBIOTIC PROPHYLAXIS
Proportion of patients who have their
antibiotic dose initiated within 1 hour
before surgical incision (2 hours
Vancomycin or a Fluoroquinolone)
Proportion of patients who receive an
approved antibiotic agent for prophylaxis
consistent with current recommendations.
Proportion of patients whose prophylactic
antibiotics were discontinued within 24
hours of the surgery end time (48 hours
for cardiac surgery)
Clindamycin use is preferred for patients
allergic to B-lactam allergy.
Vancomycin is allowed for prophylaxis of
cardiac, vascular, and orthopedic surgery if
there is a physician-documented reason in
the medical record or documented B-
lactam allergy.

2. GLUCOSE CONTROL (Cardiac Surgery Patients)
Blood glucose concentration must be
maintained<200 mg/dL for the first 2
days after surgery.
Blood glucose determination closest to
6 am on post-operative days 1 and 2
(surgery end date is postoperative day
0) is monitored.

3. HAIR REMOVAL
No hair removal should be performed; if
hair is removed, clippers or depilatory
agents should be used immediately
prior to surgery. Razors are not to be
used.

4. NORMOTHERMIA (Colorectal Surgery Patients)
Core body temperature should be
between 96.8-100.4 F within the first
hour after leaving the OR.

KEY POINTS
1. SEPSIS = infection + host response (SIRS)
a. Sepsis
b. Severe sepsis
c. Septic shock
NOTE: Rapid resuscitation, antibiotics +
source control

2. Source control- key concept
3. Principles in prophylactic antibiotic
therapy:
a. Select an agent for commonly found
organism in the site of surgery
b. Initial dose within 30 minutes
c. Re-dose for long duration surgery
d. Should no be continued for more
than 24 hours after surgery (routine
prophylaxis)
4. Principles in serious infection antibiotic
therapy:
a. Identify likely source of infection
b. Select antibiotic for particular agent
c. Inadequate antibiotic increase
mortality (start with broad
spectrum)
d. Obtain C/S and refine tx
e. If no infection is identified after 3
days, discontinue antibiotic based
on patient progress
f. Discontinue antibiotic after
appropriate course
5. SSI prevented with appropriate patient
preparation
6. Necrotizing STI- early recognition and
debridement
7. HIV- universal precaution

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