SURGICAL INFECTION, SIRS and SEPSIS

Kochs postulates
It must be found in considerable numbers in the septic focus It should be possible to culture it in a pure form from that septic focus It should be able to produce similar lesions when injected into another host

History
Ignac Semmelweis :
sepsis could be reduced by the simple act of hand-washing

Louis Pasteur & Joseph Lister :

using antiseptics to the reduction of colonising organisms in compound fractures

Alexander Fleming:
Discovery of the antibiotic penicilin

Physiology
Protective Mechanism to Prevent Infection: Mechanical: epithelial surfaces chemical: low gastric pH; humoral: antibodies, complement and opsonins; cellular: phagocytic cells, macrophages, polymorphonuclear cells and killer lymphocytes

All these natural mechanisms may be compromised by surgical intervention and treatment.

Causes of reduced host resistance to infection

Metabolic: malnutrition (including obesity), diabetes, uraemia, jaundice Disseminated disease: cancer and acquired immunodeficiency syndrome (AIDS) Iatrogenic: radiotherapy, chemotherapy, steroids

Risk factors for increased risk of wound infection

Malnutrition (obesity, weight loss) Metabolic disease (diabetes, uraemia, jaundice) Immunosuppression (cancer, AIDS, steroids, chemotherapy and radiotherapy) Colonisation and translocation in the gastrointestinal tract Poor perfusion (systemic shock or local ischaemia) Foreign body material Poor surgical technique (dead space, haematoma)

Factors that determine whether a wound will become infected

Host response Virulence and inoculum of infective agent Vascularity and health of tissue being invaded (including local ischaemia as well as systemic shock) Presence of dead or foreign tissue Presence of antibiotics during the decisive period

The risk factors for developing a wound infection

Classification of sources of infection

Primary:
acquired from a community or endogenous source

Secondary or exogenous; health careassociated infection (HAI):

acquired from the operating theatre, the ward, contamination at or after surgery

Surgical Site Infection

Major wound infections

Significant quantity of pus Delayed return home Patients are systemically ill

Minor wound infections

may discharge pus or infected serous fluid but should not be associated with excessive discomfort, systemic signs or delay in return home

Southampton Wound Grading System

Types of localised infection

Abscess Cellulitis and lymphangitis Gas gangrene Clostridium tetani Synergistic spreading gangrene (synonym: subdermal gangrene, necrotising fasciitis)

Abscesses
Abscesses need drainage with curettage Modern imaging techniques may allow guided aspiration Antibiotics are indicated if the abscess is not localised (e.g. evidence of cellulitis) Healing by secondary intention is encouraged

Abscesses
Technique of Incision and Drainage

Place a latex drain into the depth of the cavity. Fix the drain to the edge of the wound with a suture and leave in place until the drainage is minimal. Alternatively, pack the cavity open, place several layers of damp saline or petroleum gauze in the cavity leaving one end outside the wound

Cellulitis and lymphangitis

Non-suppurative, poorly localised Commonly caused by streptococci, staphylococci or clostridia SIRS is common Blood cultures are often negative

Gas gangrene
Caused by Clostridium perfringens Gas and smell are characteristic Immunocompromised patients are most at risk Antibiotic prophylaxis is essential when performing amputations to remove dead tissue

Clostridium tetani
anaerobic, Gram-positive bacterium more common in traumatic civilian or military wounds. The signs and symptoms of tetanus are mediated by the release of the exotoxin tetanospasmin high mortality Prophylaxis with tetanus toxoid

Synergistic spreading gangrene

synonym: subdermal gangrene, necrotising fasciitis
A mixed pattern of organisms Abdominal wall: Meleneys synergistic hospital gangrene scrotal infection: Fourniers gangrene Patients are immunocompromised, such as diabetes mellitus Severe wound pain, signs of spreading inflammation with crepitus and smell are all signs of the infection spreading Untreated, it will lead to widespread gangrene and MSOF.

Treatment Of Surgical Infection

When possible, tissue or pus for culture should be taken before antibiotic cover is started The choice of antibiotics is empirical until sensitivities are available Wounds are best managed by delayed primary or secondary closure

Secondary closure of wound

The wound is open, and the edges are not approximated. A potentially contaminated wound is best left open lightly packed with damp saline soaked gauze and the suture closed as delayed primary closure after 25 days

SYSTEMIC INFLAMMATORY RESPONSE AND MULTIPLE ORGAN DYSFUNCTION SYNDROMES (MODS)

Gut failure, colonisation and translocation related to the development of multiple organ dysfunction syndrome (MODS) and systemic inflammatory response syndrome (SIRS)

Systemic Inflammatory Response Syndrome (SIRS) and Sepsis

Definitions of infected states

SSI is an infected wound or deep organ space SIRS is the bodys systemic response to an infected wound MODS is the effect that the infection produces systemically MSOF is the end-stage of uncontrolled MODS

The Management of sepsis

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