Surgical Infections

SURGICAL INFECTION
SURGICAL INFECTION
SURGICAL INFECTION
SURGICAL INFECTION
SURGICAL INFECTION
 SURGICAL INFECTION

Definition:

• An infection that
requires surgical
treatment and has
developed before or as
complication of
surgical treatment.
 HISTORY

• Morton(1846)- Introduced the principles of Anesthesia

 HISTORY

• Lister(1867)
• Introduced
(carbolic acid) the
principles of
Antiseptic
technique in
Surgery
• Infection rate
dropped from 90%
to 10%.
HISTORY
 HISTORY

• Ignaz Semmelweis(1846)

• Introduced the concepts of

Asepsis (hand washing)
 HISTORY

• Ignaz Semmelweis(1846)
• Introduced the concepts of Asepsis (hand washing)
 HISTORY

• Louis Pasteur
• Developed techniques of sterilization
 HISTORY

• 1900:
• Aseptic-Ant iseptic
principles was
completed

• 1 8 6 7 to 1 9 0 0 ( 3 3 yrs.)
• Changed surgical
therapy from dreaded
event to one that
provides an enormous
alleviation of suffering
and prolongation of life
 DEFINITION OF TERMS

A person who has been colonised, but who does

Carrier
not manifest infection

Pathogen An agent with the ability to cause infection

Endogenou
Infection of the body by natural host flora
s infection

Exogenou Infection of the body by organisms not usually

s cultured from the host
infection
Nosocomia
Infection acquired during hospitalisation
l infection

Virulence The potential of a pathogen to cause infection

 DEFINITION OF TERMS

• INFECTION

• Defined by identification
of microorganisms in host
tissue or bloodstream,
plus an inflammatory
response to their
presence
 DEFINITION OF TERMS

• SYSTEMIC INFLAMMATORY
RESPONSE SYNDROME (SIRS)

• Infection in normal
individual with intact host
defenses

• With local manifestation

plus systemic manifestation
• Elevated temperature
• Elevated WBC count
• Tachycardia or
tachypnea
 DEFINITION OF TERMS

• SEPSIS

• Defined as SIRS caused

by infection

• Mediated by the
production of a
cascade of
proinflammatory
mediators produced in
response to exposure
to microbial products
 DEFINITION OF TERMS

• SEVERE SEPSIS

• Characterized as
sepsis combined
with the presence
of new-onset organ
failure
 DEFINITION OF TERMS

• SEPTIC SHOCK

• State of acute circulatory

failure identified by the
presence of persistent arterial
hypotension despite adequate
fluid resuscitation, without
other identifiable causes

• Most severe manifestation of

infection ( 4 0 %)

• With attendant mortality rate

3 0 to 66%
 OUTCOMES

• AFTER the interaction of microbes with resident and

recruited host defenses:

(a) ERADICATION

(b) CONTAINMENT

• Often lead to the presence of PURULENCE

• Hallmark of chronic infections

• (e.g., a furuncle in the skin and soft tissue
or abscess within the parenchyma of an
organ or potential space)
 OUTCOMES

• AFTER the interaction of microbes with resident and

recruited host defenses:

(c) LOCOREGIONAL INFECTION

• (cellulitis, lymphangitis, and aggressive soft

tissue infection)

• with or without distant spread of infection

(metastatic abscess)

(d) SYSTEMIC INFECTION (bacteremia or fungemia)

Relationship of Infection with SIRS
 CLASSIFICATION OF SURGICAL WOUNDS
ACCORDING TO RISK OF INFECTION

UNACCEPTABLE
TYPE DEFINITION INFECTION RATE
AT 3 0 DAYS

⚫NON-TRAUMATIC 1.0 – 2%
⚫NO BREAK IN THE TECHNIQUE

1)CLEAN ⚫RESPIRATORY, GIT, GUT NOT ENTERED

(Class I)
" class ID – WOUNDS WITH PROSTHETIC
DEVICE) e.g. Hernia repair, breast biopsy,
thyroid surgery
 CLASSIFICATION OF SURGICAL WOUNDS
ACCORDING TO RISK OF INFECTION

UNACCEPTABLE
TYPE DEFINITION INFECTION RATE
AT 3 0 DAYS

⚫GIT & RESPIRATORY TRACT ENTERED 2.1 – 9.5%

W/O SIGNIFICANT SPILLAGE (Class I)
2)CLEAN
CONTAMINATE ⚫MINOR BREAK IN THE TECHNIQUE
4% - 14%
D
(Class II)
" E.g. class I Cholecystectomy
Class I " GI surgery (not colon)
Class II
" Class II Colorectal surgery
 CLASSIFICATION OF SURGICAL WOUNDS
ACCORDING TO RISK OF INFECTION

UNACCEPTABLE
TYPE DEFINITION INFECTION RATE AT
3 0 DAYS

⚫MAJOR BREAK IN THE TECHNIQUE

⚫FRESH TRAUMATIC WOUND
⚫GROSS SPILLAGE FROM GIT, GUT &
RESPIRATORY TRACT IN THE
PRESENCE OF INFECTED URINE OR
3)CONTAMINATED
BILE 3.4 – 13.2%
WOUND (Class III)

" e.g. Penetrating abdominal trauma

" Large tissue injury
" Enterotomy during large bowel
obstruction
 CLASSIFICATION OF SURGICAL WOUNDS
ACCORDING TO RISK OF INFECTION

UNACCEPTABLE
TYPE DEFINITION INFECTION RATE AT
3 0 DAYS

⚫TRAUMATIC WOUNDS W / RETAINED

DEVITALIZED TISSUE, FOREIGN BODIES,
FECAL MATERIAL, OR DELAYED
4 ) DIRTY TREATMENT, OR FROM A DIRTY SOURCE.
WOUND 3.1 – 12.8%
(CLASS IV) ⚫PERFORATED VISCUS

" e.g. Perforated Diverticulitis

" Necrotizing soft tissue infection
 HISTORY and PE

# Provide the basis for Diagnosis

# Classic signs and symptoms of infection:

1. Redness due to intense hyperemia

2. Swelling
3. Heat
4. Pain
5. Loss of function
6. Fever and Chills
 LABORATORY

1) WBC count

2) Gram Stain

3) Bacterial Analysis

4)Culture and Sensitivity

test

5) Biopsy
 Causes of Wound Infection

Infection of surgical
wounds occur whenever
the microbial inoculum
in the wound is sufficient
to overcome the local
host defense mechanisms
and established
progressive growth.
 CAUSES OF W O U N D INFECTION

# Bacterial Factors

# Local Wound Factors

# Patient Factors
 (1) Bacterial Factors

1)DEPOSITION and GROWTH of

BACTERIA
• Prerequisite for the
development of infection

2)TYPES & NUMBER OF

BACTERIA
• Contribute significantly to
establish overt infection
 Bacterial Factors

3) SURFACE COMPONENT
• Contribute to pathogenicity by
inhibiting phagocytosis

• ENDOTOXIN
• Complex
lipopolysaccharide of
the bacterial cell wall
• Produced by gram
negative bacteria

• EXOTOXIN
• Specific, soluble,
diffusible,prot eins
produced by
bacteria
 Bacterial Factors

3) SURFACE COMPONENT
• Contribute to pathogenicity by
inhibiting phagocytosis

• ENDOTOXIN
• Complex
lipopolysaccharide of
the bacterial cell wall
• Produced by gram
negative bacteria

• EXOTOXIN
• Specific, soluble,
diffusible,prot eins
produced by
bacteria
 Bacterial Factors

4)BACTERIAL
CONTAMINATION
• Greater than
1 0 0 , 0 0 0 organisms
(colony forming
units (CFU)/ml)
frequently causes
infection

• Contamination with
less than 1 0 0 , 0 0 0
usually do not cause
infection
 (2) Local Wound Factors

1)Inhibition of local
defense mechanisms
forclearing bacteria.

2)Inhibition of the
phagocytic cells to
directly contact and kill
the bacteria
 (3) Patient Factors

1. Age
• Wound infection are very common among the very
old and young individuals because of the immature
and senescent resistance mechanisms

2. Reduction in the blood flow

3. Reduction in vascular reactivity

4. Presence of malignancy and trauma

 (3) Patient Factors

Infections that result from operative

treatment:

• SSI
• Intra abdominal abscess
• Tertiary peritonitis
• Prosthetic device–related
infection
• Other hospital-acquired
infections:
• Pneumonias
• Urinary tract infection
• Vascular catheter–
related infection
 PREVENTION OF W O U N D INFECTION

• Far more practical than

treatment when established

• Strict adherence to the

principle of wound care

• Application of the basic

knowledge concerning
pathogenesis of wound
infections prevent majority
of infectious complication.
 PREVENTION OF W O U N D INFECTION

1. Avoidance of Bacterial Contamination

2. Operating Room Team and Discipline

3. Avoidance of Endogenous Contamination

4. Importance of Surgical Technique

5. Systemic Factors

6. Systemic Prophylactic Chemotherapeutic and Antibiotic

 (1) Avoidance of Bacterial Contamination

A. ENVIRONMENTAL FACTORS

• Avoid exogenous and endogenous contamination

• Use of ultraviolet light and laminar flow ventilation
• Limitation of traffic in and out of the operating
room.
• Limitation of activity and talking within the
operating room
 (1) Avoidance of Bacterial Contamination

B. PREOPERATIVE
PREPARATION OF PATIENT

• Preoperative shower w /
antimicrobial soap
(chlorhexidine)

• Cutaneous
infection should be
controlled or
cleared before
elective operation
 (1) Avoidance of Bacterial Contamination

C. HAIR REMOVAL
• Injury from SHAVING may
promote bacterial growth to
100% infection rate

• Seropian and Reynolds:

• A study of 4 0 6 clean wounds
showed that shaving
increases infection rate to
5.6% from 0.6% where no
shaving was done.

• Hamilton et al:
• Used electron microscope and
showed that shaving
produced gross cuts on the
skin
 (1) Avoidance of Bacterial Contamination

D. Skin preparation

• Scrub the operative

area for 5 to 7 minutes
w / germicidal solution

• Paint w / povidine-
iodine or chlorhexidine

• Use an antimicrobial
incision drape
 (2) Operating Room Team and Discipline

• Wear clean scrub suits, cap

and mask

• Scrub hands and forearms

w / antimicrobial soap

• Careful wearing of gown

and gloves

• Careful draping of the

patient

• Change puncture or tear

gloves
 (3) Preventing Endogenous Contamination

• Avoid bacterial contamination of the surgical

wound at the time of transection of the
GIT,GUT, and respiratory tract.
SOURCE CONTROL

The primary precept of

SURGICAL INFECTIOUS DISEASE
therapy consists of:

1. Drainage of all purulent

material

2. Debridement of all infected,

devitalized tissue, and debris,
and/or removal of foreign
bodies at the site of infection

3. Remediation of the underlying

cause of infection
 (4) Importance of Surgical Technique

• Gentle care of tissues to minimize local damage

• All devitalized tissues and foreign bodies should be

removed

• Use monofilament sutures for potentially infected

wound

• Avoid the presence of hematomas, seromas and dead

spaces
 (5) Systemic Factors

• Host resistance
• Correction and control of systemic diseases

• Correct underlying malnutrition

• Avoid disturbance of circulation

• Avoid unnecessary use of drugs in surgical patient

 (5) Systemic Prophylactic Chemotherapy & Antibiotics

• Use should be based on weight of evidence on possible

benefits vs. weight of evidence on possible adverse effects

• Avoid indiscriminate use of antibiotics as it may lead to:

• Secondary infection or superimposed infection

• Hypersensitivity reactions
• Masking of signs and symptoms of infection
• Development of antibiotic resistant strains
 (5) Systemic Prophylactic Chemotherapy & Antibiotics

PROPHYLAXIS

• Consists of the administration of an antimicrobial agent

or agents PRIOR TO and DURING initiation of certain
specific types of surgical procedures to reduce the
number of microbes that enter the tissue or body cavity

• Usually only a single dose of antibiotic is required

• Patients to undergo complex and prolonged operations

should receive additional dose/s of antibiotics
 (5) Systemic Prophylactic Chemotherapy & Antibiotics

PROPHYLAXIS

• Empiric therapy

• Entails the use of an antimicrobial agent or agents

when the risk of a surgical infection is high, based
on the underlying disease process.

• Limited to a short course of drug ( 3 to 5 days).

 Principles o f Antibiotic T h e r a p y

GENERAL PRINCIPLE:

• Goal of therapy is to achieve

level of antibiotics at the site
of infection that exceeds the
minimal inhibitory
concentration of the
pathogen present

• Mild infection —> ORAL

antibiotics
• Severe infection —> IV
antibiotics
 Principles o f Antibiotic T h e r a p y

IF obvious improvement is not observed w /

in 2 to 3 days:

• Initial operative procedure is NOT adequate

• Initial procedure is adequate but

complication has occurred

• Superinfection has developed at new site

• Drug of choice is correct but not

sufficiently administered

• Another or different drug is needed

 Principles o f Antibiotic T h e r a p y

$ A good guideline is to continue the antibiotics

until the patient has demonstrated an obvious
clinical improvement based on clinical
examination:
• Improved mental status
• Return of bowel function
• Spontaneous diuresis
 Principles o f Antibiotic T h e r a p y

• SUPERINFECTION

• A new infection that develops during the antibiotic

treatment for the original infection.
• e.g. respiratory tract infection that develops
during treatment of intra-abdominal infection

• Occurs in 2 to 10% of antibiotic treated patient

• Best preventive treatment: Limit the dose and duration

of antibiotic treatment.
 Principles o f Antibiotic T h e r a p y

ANTIBIOTIC

• Chemical compound derived from or produced by living

organisms

• Capable of inhibiting the life process of the

microorganisms at a low concentration

• Aim:
• To control or eradicate bacterial infections before or
during hospitalization to prevent infection from
developing post-operatively.
 Principles o f Antibiotic T h e r a p y

FUNDAMENTAL PRINCIPLES GOVERNING THE USE OF

ANTIBIOTICS:

1. The agent administered is active against the infecting

microorganisms

2. Adequate contact between the drugs and the infecting

microbe

3. Absence of toxic side effects or complication

4. Utilization of host defenses to augment the antibacterial

effects of the antibiotics
 Principles o f Antibiotic T h e r a p y

CLASSIFICATION OFANTIBIOTICS

A. BACTERIOSTATIC
• Agents that prevent the growth of bacteria but do not
destroy them.
• Affects early stages of protein synthesis in the
ribosomes

B. BACTERICIDAL
• Agents that actively kill the bacteria
• Causes the ribosome to miscode and consequently
induce the manufacture of defective proteins and
enzymes that poison the cell.
 CELLULAR SITE of
BACTERICIDAL BACTERIOSTATIC
INHIBITION
Penicillins
Cephalosphorin
1 ) Cell wall synthesis s Vancomycin
Bacitracin
Polymyxin B Nystatin
2 ) Barrier function of
Colistin
cell membrane
Amphotericin B
Streptomycin Tetracycline
3 ) Protein synthesis Aminoglycosides Chloramphenico
in the ribosome l Erythromycin
Clindamycin
4 ) DNA replication in Griseofulvin
chromosomes
 Principles o f Antibiotic T h e r a p y

1. PENICILLINS

• Share the 6-aminopenicillanic acid nucleus in w /c the beta

lactam ring is essential for the antibacterial activity

• BACTERICIDAL
• Bind to receptors and block the synthesis of the
bacterial cell wall MUCOPEPTIDE producing osmotic
instability and causing lysis

• Most effective during the stage of active bacterial

multiplication

• Active against most gram positive organisms

 Principles o f Antibiotic T h e r a p y

2. CEPHALOSPORINS

• Related to penicillin

• Possess a nucleus of 7-aminocephalosporanic acid

• BACTERICIDAL
• Inhibits bacterial cell wall synthesis

• Arranged into generations based on expanding activity

against gram negative bacteria

• Biological target: Penicillin-binding proteins

 Principles o f Antibiotic T h e r a p y

3. ERYTHROMYCIN/AZITHROMYCIN (Macrolides)

• Bacteriostatic but may be bactericidal in higher concentration

• Inhibit bacterial protein synthesis

• Second choice in patients sensitive to penicillins

• Treatment of choice for Mycoplasmal infection and

Legionnaire’s disease

• Useful in the treatment of Actinomycosis

 Principles o f Antibiotic T h e r a p y

4. TETRACYCLINES

• Active against gram positive and many gram negative organisms

that are not sensitive to penicillin
• (e.g. T pallidum and TB)

• Bacteriostatic

• They interfere w / protein synthesis

• Usually administered orally

• Used in the treatment of Actinomycosis and Nocardiosis

• Avoided in early childhood due to deposition in the early stages of

calcification causing yellow discoloration of the teeth.
 Principles o f Antibiotic T h e r a p y

5. CHLORAMPHENICOL

• Broad spectrum and bacteriostatic

• Inhibits protein synthesis
• Well-absorbed orally and pareterally
• Toxic side effects:
• Aplastic anemia (bone marrow depression)
• Gray syndrome ( deficiency In detoxifying enzymes )
• Drug of choice for typhoid fever and other salmonella
infection
• Life-saving drug in patients w / meningitis
• Drug of choice in the treatment of H. Influenzae if pt. is
allergic to penicillin
 Principles o f Antibiotic T h e r a p y

6. AMINOGLYCOSIDES

• Bactericidal

• Inhibit protein synthesis by disorganizing the proper

placement of mRNA to bacterial ribosome

• Wide range of activity against gram negative and gram

positive bacteria and mycobacteria

• Toxic side effects:

• Overdosage leads to damage of the auditory
branch of the 8th nerve
• Nephrotoxic
 Principles o f Antibiotic T h e r a p y

7. METRONIDAZOLE

• Bactericidal against all clinically important obligate

anaerobic bacteria

• Used as preoperative prophylactic agent against

post-operative morbidity

• Used in the treatment of T. Vaginitis, Intestinal

amoebiasis, and Giardiasis
 Principles o f Antibiotic T h e r a p y

8. AMPHOTERICIN B

• The only antifungal agent

effective against systemic
mycotic infections

• Administered intravenously,
intrathecally or instilled
directly to the site of
infection
 Principles o f Antibiotic T h e r a p y

9. SULFONAMIDES- Trimethoprim

• Effective against community

acquired gram negative
infections

• Orally administered

• Widespread resistance but has

limited their usefulness in
nosocomial infection
 Principles o f Antibiotic T h e r a p y

10. 4- FLUOROQUINOLONES

• More recent class of antibiotics introduced mainly for

use in hospital acquired infections.

• Wide range of activity against nearly all gram negative

organisms

• High absorption in the duodenum

 Principles o f Antibiotic T h e r a p y

10. CARBAPENEMS

• Currently has the widest spectrum

• Highly effective against:

• Most aerobic bacteria(s. aureus, p. aeruginosa)
• Anaerobic bacteria ( b. fragilis, e. coli)
Classification o f Bacteri a b y G r a m Stain & Morphology

COCCI BACILLI

Bacillus
GRAM Staphylococci Clostridia
POSITIVE Streptococci Corynebacteria
Listeria
Mycobacterium

Pseudomonas
Escherischia )
Yersinia )
Salmonella )
Shigella )
Enterobacteria
Klebsiella )
GRAM Proteus )
NEGATIVE Neisseria Vibrio )
Haemophilus )
Bordatella )
Parvobacteria
Brucella )
Serratia )
Campylobacter
Bacteroides
 Class of surgical procedure
Parameter
Class I Class II Class III Class IV

Transection with major

GI, GU, spillage
Transection with minor Dead tissue, direct
tracheobronchial Intact spillage Incision through infection, pus
system integrity infected tissue

Contamination despite
Sterile technique Continuous Minor lapses Interrupted sterile technique

Antibiotic prophylaxis Not required Single dose Broad spectrum Broad spectrum

12%
Wound infection rate 1.5% < 8% 15-25% without > 25%
antibiotics

Contaminated with pus,

Surgical wound Nontraumatic faeces or extraneous
Mildly contaminated Grossly contaminated
produced Uninfected material

Endocrine Elective GI Abscesses

Orthopaedics Dental GI perforation Faecal peritonitis
Examples
Skin Gynaecological Open fracture reduction Trauma > 4 hours
 Likely infecting
Type of surgery Prophylactic antibiotic
organism

Cardiac

Vascular

Prosthesis placement S aureus Cefuroxime 750mg iv

Coagulase negative or
Neurosurgery Vancomycin 15mg/kg iv (if
staphylococci
cephalosporin sensitive)

Thoracic

Orthopaedic

G- bacilli, S aureus
Gastrointestinal S faecalis
Anaerobes

Cefuroxime 750mg iv
G- bacilli, S aureus +
Obstetric/gynaecological Group B streptococci Metronidazole 500mg iv
Anaerobes +/-
Gentamicin 5mg/kg iv
(3mg/kg in renal disease)

Head and neck S aureus

(including dental) Streptococci
Anaerobes

Gentamicin 120mg iv
Gram – bacilli Amoxycillin/clavulanic acid 1.2g
Urological S faecalis iv
 C o m m o n Empirical R e g i m e n s

• Minor surface infections

• Narrow spectrum: flucloxacillin (if S aureus)
suspected
• Broad spectrum: cefuroxime

• Chest infections: Penicillins

• After GI surgery:
• Cefuroxime + metronidazole + / - gentamicin
• + / - Antifungal

• After urological surgery:

• Co-amoxiclav
• Gentamicin
 C o m m o n Empirical R e g i m e n s

• Severe sepsis:
• Vancomycin + gentamicin + metronidazole

• MRSA:
• Vancomycin

• Vancomycin-resistant enterococcus (VRE):

• Consult microbiologist

• Pseudomonas suspected:
• Ciprofloxacin
 Main G r o u p o f Antibiotics

Effective
Antibiotic Site of action against Side effects

Broad spectrum Hypersensitivity

Beta-lactams or narrow Nausea, vomiting,
Bacterial cell wall
(penicillins, cephalosporins) spectrum diarrhoea (NVD)

Bacterial
Antimetabolites tetrahydrofolate
Urinary Blood dyscrasias
(sulphonamides, production
infections Rashes
trimethoprim) ( ¼ purine
synthesis)

Glycopeptides Severe G+ Blood dyscrasias

Bacterial cell wall
(vancomycin, teicoplanin) infections Renal impairment

NVD
Quinolones Bacterial DNA G- infections
Cytochrome P450
(e.g. ciprofloxacin) gyrase Pseudomona
inhibition
s
Liver enzyme
Bacterial DNA
G+ cocci induction
Rifampicin dependant RNA
Mycobacteria Deranged LFTs
polymerase
Orange urine
 Main G r o u p o f Antibiotics

Antibiotic Site of action Effective against Side effects

) Bacterial G+ cocci NVD

) 50S ribosomal Bacilli Cholestatic jaundice

Protein synthesis inhibitors ) subunit G- bacteria Blood dyscrasias

Macrolides (erythromycin) ) (esp. gynae flora) Grey baby syndrome

Chloramphenicol ) Bacterial G- organisms Adsorbs onto growing

Tetracyclines ) 30S ribosomal bones and teeth

Aminoglycosides (gentamicin) ) subunit Ototoxicity

) Nephrotoxicity

Forms high energy NVD

bactericidal free Antabuse effect
Metronidazole Anaerobes
radicals due to low Taste
redox potential Neuropathy

Azole antifungals Yeasts Mild liver enzyme

Fungal membrane
(e.g. fluconazole) Candida induction

Deranged K, Mg and LFTs

Membrane sterols
Polyene antifungals Many fungal Nephrotoxicity
(bacteria and
(e.g. amphotericin B) species Anaemia
humans)
NVD
 Surgical Microbiology

• BACTERIA

• Classified according to:

1. Staining characteristics with gram stain

• Gram-positive
• Gram-negative

2. Shape
• Cocci
• Rods
• Spirals

3. Sensitivity to oxygen (aerobic,facultative,anaerobic )

 Surgical Microbiology

• Gram positive cocci

• Pyogenic cocci
• Staphlococcus
• St reptococcus
 Surgical Microbiology

Staphylococcus aureus

• Most common pathogen isolated from wound infection

• Major factors of pathogenicity:

1. Coagulase production

2. Cell wall peptidoglycan

• Inhibits edema production and migration of leukocytes

3. Capsules
• Inhibit phagocytosis
 Surgical Microbiology

Staphylococcus aureus

• Major factors of pathogenicity:

4. Exopolysaccharides or glycocalyx (slime)

• Permit bacteria to resist phagocytosis and adhere to prosthetic
materials

5. Enterotoxin (food poisoning)

6. Epidermolytic toxin (cause variety of skin lesions)

7. TSS toxin I (toxic shock syndrome)

 Surgical Microbiology

STREPTOCOCCUS

• Surgically important
members:
• S. pyogenes
• S. pneumoniae
• S. viridans
 Surgical Microbiology

STREPTOCOCCUS

• Classified according to lancefield classification

• Based on cell surface antigen and ability to cause
hemolysis on blood agar

1. Alpha hemolysis
• Zone of green discoloration around colonies containing
intact RBC

2. Beta hemolysis
• Complete clearing of the area around colonies and
destruction of RBC

3. Gamma hemolysis
• No hemolysis
 Group A Streptococcus

PATHOGENICITY

• Cell surface components and extracellular products that inhibit

host defense or promote spread of bacteria

1. Cell surface M protein and the capsule

• Help resist phagocytosis

2. Hyalurodinase and streptokinase

• Promote spread of infection

3. Streptolysin O and streptolysins

• Hemolysins
 Group A Streptococcus

PATHOGENICITY

4. Streptococcal proteinase
• May be responsible for
tissue invasion

5. Pyogenic exotoxins
• Share many properties with
endotoxins from gram
negative bacteria
• Cause infection of almost
any organ
• e.g. s. pyogenes cause
pharyngitis giving rise to
scarlet fever and rheumatic
fever
 Aerobic a n d Facultative Gram- n e g ativ e Bacilli

• Has replaced gram positive cocci as the cause of most

surgical infections other than wound infection

• Cell walls have common chemical constituents:

• Lipopolysaccharides or endotoxin w / c is
responsible for most of the biologic effects of
bacteria
 C o m m o n P a t h o g e n s in Surgical P a t i e n t s

Gram positive aerobic cocci

• Staphylococcus aureus
• Staphylococcus epidermidis
• Staphylococcus pyogenes
• Streptococcus pneumoniae
• Ent erococcus faecium, E. faecalis
 C o m m o n P a t h o g e n s in Surgical P a t i e n t s

Gram negative aerobic bacilli

• Escherichia coli
• Haemophilus influenzae
• Klebsiella pneumoniae
• Proteus mirabilis
• Enterobacter cloacae, E. aerogenes
• Serratia marscescens
• Acinetobacter calcoaceticus
• Citrobacter freundii
• Pseudomonas aeruginosa
• Xanthomonas maltophilia
 C o m m o n P a t h o g e n s in Surgical P a t i e n t s

ANAEROBES
• Unable to grow or divide poorly in air
• Do not possess the enzyme catalase (w /c allows for
metabolism of reactive oxygen species)
• Predominantly indigenous flora in may areas of the human
body

• Gram positive
• Clostridium perfringens
• C. tetani, C. septicum
• Clostridium difficile
• Peptostreptococcus spp.

• Gram negative
• Bacteroides fragilis
• Fusobacteruim spp.
 Types o f Surgical Infections

CELLULITIS

• Nonsuppurative inflammation of
the subcutaneous tissues extending
along the connective tissue planes

• Widespread swelling, redness and

pain without definite localization

• Hemolytic streptococci are the

classic etiologic agent
 Types o f Surgical Infections

CELLULITIS

• TREATMENT

• Antibiotics
• Rest
• Incision and
drainage (I&D) if
inflammation fail to
subside w/in 2 4
hours
 Types o f Surgical Infections

CELLULITIS

• TREATMENT

• Antibiotics
• Rest
• Incision and
drainage (I&D) if
inflammation fail to
subside w/in 2 4
hours
 Types o f Surgical Infections

LYMPHANGITIS

• Inflammation of lymphatic
pathway

• Usually visible as erythematous

streaking of the skin

• Caused by hemolytic
streptococci

• Usually a defense of the body to

a distal infection in the extremity

• TREATMENT:
• Antibiotics
• Rest
 Types o f Surgical Infections

LYMPHANGITIS

• Inflammation of lymphatic
pathway

• Usually visible as erythematous

streaking of the skin

• Caused by hemolytic
streptococci

• Usually a defense of the body to

a distal infection in the extremity

• TREATMENT:
• Antibiotics
• Rest
 Types o f Surgical Infections

ERYSIPELAS
• Acute spreading cellulitis and
lymphangitis
• Usually caused by hemolytic
streptococci with raised,
sharply defined, irregular,
reddish borders
• Gain entrance through a
break in the skin
• There is a distinct
demarcation at the margin of
infection
 Types o f Surgical Infections

ERYSIPELAS
• S/S:
• Abrupt onset of chills,
fever and prostration
• Commonly involves the
face:
• “Butterfly lesion” over
the nose and cheek
• TREATMENT:
• Antibiotics
 Types o f Surgical Infections

SUBEPITHELIAL ABSCESS

• Localized collection of pus

surrounded by an area of
inflamed tissues
underneath the corium of
the skin

• There is leukocytic
infiltration
Abscess
Abscess
 Types o f Surgical Infections

FURUNCLE or BOIL

• Painful nodule formed in the skin

by a circumscribed inflammation
of the corium and subcutaneous
tissue

• Presence of:
• Central core of necrosis w /
• Peripheral zone of cellulitis

• Caused by bacterial infection of

the sweat gland and hair follicles

• TREATMENT:
• Antibiotics
• Incision & Drainage
 Types o f Surgical Infections

IMPETIGO

• Acute contagious skin disease

characterized by the formation of
a series of intraepitheleal abscesses

• Appears as multiple small pustules

that extend and coalesce to form
large areas of cutaneous gangrene
and ulceration

• Usually a complication of a
debilitating disease caused by
hemolytic streptococci and
staphylococcus
Impetigo
 Types o f Surgical Infections

CARBUNCLE
• Multilocular suppurative extension of
a furuncle into the subcutaneous
tissues

• Multiple draining sinuses w /

indurated borders

• Usually located at nape, dorsum of

the trunk, hands and digits, hirsute
portion of the chest and abdomen

• Caused by pyogenic cocci usually

staphlylococcus aureus

• Treated by wide excision and

antibiotics
 Types o f Surgical Infections

CARBUNCLE
• Multilocular suppurative extension of
a furuncle into the subcutaneous
tissues

• Multiple draining sinuses w /

indurated borders

• Usually located at nape, dorsum of

the trunk, hands and digits, hirsute
portion of the chest and abdomen

• Caused by pyogenic cocci usually

staphlylococcus aureus

• Treated by wide excision and

antibiotics
 Types o f Surgical Infections

NECROTIZING FASCIITIS
• superficial and widespread fascial
necrosis
• extreme systemic toxicity
• 90% caused by beta hemolytic
streptococcus, 10% by gram
negative enteric pathogen
• diagnose by the presence of
serosanguinous exudate, swollen,
stringy, dull gray necrotic fascia
w / extensive undermining
• treated w / multiple linear incision
and antibiotics