Dr.

Hatem ElGohary
Lecturer of General Surgery MD, MRCS
PHYSIOLOGY
 Micro-organisms are normally prevented from
causing infection in tissues by intact epithelial
surfaces. These are broken down in trauma and
by surgery.

 Protective mechanisms against infection can be

divided into:
• Chemical: low gastric pH;
• Humoral: antibodies, complement and
opsonins;
• Cellular: phagocytic cells, macrophages,
killer lymphocytes.
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)
CLINICAL PICTURE
 Symptoms

Fever

Throbbing pain

Pus or watery discharge

 Signs
Redness

excessive swelling in
the wound

tenderness in the
wound area
Wound Classification
 Class I (Clean)
Operative wound clean, no inflammation,
Respiratory, gastrointestinal and genitor-
urinary tracts not entered.

Examples: Thyroidectomy, mastectomy.

Infection rate: 1-2%
 Class II (Clean Contaminated)
Operative wound clean-contaminated
Gastrointestinal, respiratory or genitor-urinary
tracts entered without significant spillage

Examples: Appendectomy, cholecystectomy.

Infection rate: 20-30 %
 Class III (Contaminated)
Operative wound contaminated
Gross spillage from the gastrointestinal
tract, genito-urinary or biliary tracts.

Example: Colectomy.
Infection rate: up to 60%
 Class IV (Dirty Infected)
Operative wound dirty
Traumatic wound from dirty source, Fecal
contamination, Foreign body.

Examples: Drainage of Abscess

Debridement of Diabetic foot.
Infection rate: more than 60%.
Types of localized infection
Abscess (Acute suppurative inflammation
+Localized Collection of pus).
 Caused by Staphylococcus aureus
 Pus (dead and dying white blood cells).
 Surrounded by Pyogenic membrane.
 C/P: Redness, Hotness, Tenderness
and edema.
 Treatment: Incision and drainage.
Cellulitis and Lymphangitis (non suppurative
diffuse inflammation).

 Caused by β-haemolytic streptococci.

 C/P: Redness, Hotness, Tenderness and
edema.
 Treatment: Antibiotics.
Specific wound infections
Gas gangrene
 Caused by C. perfringens. Gram-positive,
anaerobic bacilli found in soil and faeces.
 Common in wounds containing necrotic or
foreign material.
 C/P: severe local wound pain and crepitus (gas
in the tissues).
 X-ray: Gas in tissues.
 Treatment: 1.Intravenous penicillin.
2.Aggressive debridement of
affected tissues.
Tetanus
 Caused by Clostridium tetani (anaerobic, Gram-
positive bacterium).

 common in traumatic civilian or military wounds.

 Mechanism: release of the exotoxin tetanospasmin,

which affects myo-neural junctions and the motor
neurones of the anterior horn of the spinal cord.

 C/P: prodromal period, leads to spasms in the

distribution of the motor nerves of the face followed by
the development of severe generalised motor spasms
respiratory arrest and death.
 Treatment:
1. Prophylaxis with tetanus toxoid is the
best preventative treatment
2. Debridement of the wound may need to
be performed.
3. Antibiotic treatment with benzylpenicillin
4. Ventilation in respiratory spasm.
TREATMENT OF SURGICAL
INFECTION
Prophylaxis
1.Prophylactic antibiotics
 Maximal blood and tissue levels should be
present at the time incision is made
 Givin at induction of anaesthesia.
 The choice of an antibiotic depends on the
expected spectrum of organisms likely to
be encountered.
 Patients with known valvular disease of the
heart, prophylactic antibiotics during dental,
urological or open viscus surgery.
2.Preoperative preparation

 Short preoperative hospital stay lowers the

risk of acquiring infection.
 Medical staff should always wash their
hands between patients.
 personal hygiene is vital.
 Staff with open, infected skin lesions
should not enter the operating theatres.
 Antiseptic baths.
 Preoperative shaving immediate before
surgery.
3.Scrubbing and skin preparation

 Aqueous antiseptics should be used,

and the scrub should include the nails,
washing to the elbows e.g. Betadine or
alcohol.
4.Intra-Operative care
 Numbers of staff in the theatre and
movement in and out of theatre should
be kept to a minimum.

 dead spaces and haematomas should

be avoided and the use of diathermy
kept to a minimum.
Postoperative care of wounds

 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.
The use of Anti-microbials

 The use of antibiotics for the treatment

of established surgical infection ideally
requires recognition and determination
of the sensitivities of the causative
organisms.
 choice being empirical and later
modified depending on microbiological
findings.
 Drainage of pus should not be delayed.
Types of antibiotics use
 A narrow-spectrum antibiotic may be
used to treat a known sensitive infection.

 Combinations of broad-spectrum
antibiotics can be used when the
organism is not known.
Precautions In HIV Patients
• Use of a full face mask ideally, or protective spectacles.

• use of fully waterproof, disposable gowns and drapes

• boots to be worn, not clogs, to avoid injury from dropped

sharps;

• double gloving needed

• allow only essential personnel in theatre;

• avoid unnecessary movement in theatre;
• respect is required for sharps, with passage in a kidney dish;
• a slow meticulous operative technique is needed with minimised
bleeding.