1. Surgical Infections, Antibiotics & Asepsis Dr.Mohd AlAkeely Associate Professor & Consultant General Surgery

2. 1.To be able to diagnosed, investigate and manage common community acquired infections. 2.To have a basic understanding of prevention and management of hospital acquire infection (nosocomial). 3.To have a basic understanding of the methods of Asepsis and its implications. 4.To have a guideline in the use of antibiotics for both therapy and prophylaxic and the awareness of main side effects of commonly used antibiotics. 1.To be able to diagnosed, investigate and manage common community acquired infections. 2.To have a basic understanding of prevention and management of hospital acquire infection (nosocomial). 3.To have a basic understanding of the methods of Asepsis and its implications. 4.To have a guideline in the use of antibiotics for both therapy and prophylaxic and the awareness of main side effects of commonly used antibiotics. Objectives:

3. . Sabiston Textbook of Surgery 18 th Edition Pages 299- 327. Schwartz Principles of Surgery 8 th Edition Pages 109- 127 Baily & love 24 th edition. Sabiston Textbook of Surgery 18 th Edition Pages 299- 327. Schwartz Principles of Surgery 8 th Edition Pages 109- 127 Baily & love 24 th edition References:

4. Definition; it is the infection which requires surgical treatment 0R a complication of a surgical Rx. It accounts for one-third of surgical patients. Important complication of any invasive procedure. Definition; it is the infection which requires surgical treatment 0R a complication of a surgical Rx. It accounts for one-third of surgical patients. Important complication of any invasive procedure. Introduction

5. For an infection to develop, four factors: 1- adequate dose of the microorganism. 2- virulence of the organism. 3- susceptible host. 4- suitable environment. For an infection to develop, four factors: 1- adequate dose of the microorganism. 2- virulence of the organism. 3- susceptible host. 4- suitable environment.

6. Is the ability of bacteria to produce toxins or resist phagocytosis ( encapsulated organisms ). There are two types of toxins: - exotoxins. - endotoxins. Is the ability of bacteria to produce toxins or resist phagocytosis ( encapsulated organisms ). There are two types of toxins: - exotoxins. - endotoxins. The virulence

7. Lipopolysaccharides Part of gram – ve bacterial wall [ released after destruction of bacteria]. Do not have specific effects for each type of bacteria It causes gram – ve shock (septicemea) Lipopolysaccharides Part of gram – ve bacterial wall [ released after destruction of bacteria]. Do not have specific effects for each type of bacteria It causes gram – ve shock (septicemea) Endotoxins

8. * Soluble proteins * Released from intact bacteria (gram +ve & -ve) * Have specific effects for each type of bacteria * Their effects are local and remote from the site of release * Soluble proteins * Released from intact bacteria (gram +ve & -ve) * Have specific effects for each type of bacteria * Their effects are local and remote from the site of release Exotoxins

9. Pathogenic potential is exalated by;. genetic mutation ( e.g. β-lactamase of staph.aureus).. Synergesty Pathogenic potential is exalated by;. genetic mutation ( e.g. β-lactamase of staph.aureus).. Synergesty

10. Intact skin & mucous membrane. Good inflammatory response. Intact acquired immunity. Intact skin & mucous membrane. Good inflammatory response. Intact acquired immunity. Host resistance:

11. Phagocytosis and intraleucytic microbicidal system is Affected by:  Poor blood perfusion  low oxygenitation  Hypothermia Phagocytosis and intraleucytic microbicidal system is Affected by:  Poor blood perfusion  low oxygenitation  Hypothermia

12. Clinical features: * Local features of inflammation (may not be all present ). * Systemic symptoms. Investigations : * CBC, ESR, CRP. * Sample for gram stain & culture. * Others. eg; serology & radiology. Clinical features: * Local features of inflammation (may not be all present ). * Systemic symptoms. Investigations : * CBC, ESR, CRP. * Sample for gram stain & culture. * Others. eg; serology & radiology. Diagnosis of infection

13. Debridement of wounds ( necrotic tissue ). Drainage of pus. Removal of the source and foreign bodies. eg: appendicectomy and cholecystectomy Supportive measures. Debridement of wounds ( necrotic tissue ). Drainage of pus. Removal of the source and foreign bodies. eg: appendicectomy and cholecystectomy Supportive measures. Principles of treatment

14. Cellulitis Erysipelas Lymphangitis Boil (Furuncle) Carbuncle Hidradenitis suppurativa Necrotizing fasciiti Gas gangrene & tetanus Pseudo memranous colitis Cellulitis Erysipelas Lymphangitis Boil (Furuncle) Carbuncle Hidradenitis suppurativa Necrotizing fasciiti Gas gangrene & tetanus Pseudo memranous colitis Surgical infection

15. 1- cellulitis :. Spreading infection of skin & subcutaneous tissue. very common. Caused by streptococcus ( mainly ) & staph. The area affected becomes red, hot, painful indurated and tender. 1- cellulitis :. Spreading infection of skin & subcutaneous tissue. very common. Caused by streptococcus ( mainly ) & staph. The area affected becomes red, hot, painful indurated and tender. Common surgical infections

20. Treatment:  Penicilline  ( or erythromycin in sensitive patients).  Rest & elevation of the affected limb.  Hospital admission in severe cases. Treatment:  Penicilline  ( or erythromycin in sensitive patients).  Rest & elevation of the affected limb.  Hospital admission in severe cases.

21. . Superficial spreading cellulitis & lymphangitis. Area of redness, sharply defined irregular border. Follows minor skin injuries. Organism-Strep pyogenes. Penicillin, Erythromycin. Superficial spreading cellulitis & lymphangitis. Area of redness, sharply defined irregular border. Follows minor skin injuries. Organism-Strep pyogenes. Penicillin, Erythromycin Erysipelas.

24. 2- lymphangitis : Inflammation of lymphatic pathway caused by hemolytic streptococci ( usually secondary to cellulitis ). * Appears as red streaks on extremities. * Treatment: antibiotics, rest and elevation. 2- lymphangitis : Inflammation of lymphatic pathway caused by hemolytic streptococci ( usually secondary to cellulitis ). * Appears as red streaks on extremities. * Treatment: antibiotics, rest and elevation.

26. Necrosis of subcutaneous tissue underlying the skin. usually Polymicrobial infection. Common sites are: abdominal wall, perineum and limbs. Usually follows abdominal surgery or trauma. Immune compromised [ e.g.Diabetics and IV drug addicts ] are more susceptible. Necrosis of subcutaneous tissue underlying the skin. usually Polymicrobial infection. Common sites are: abdominal wall, perineum and limbs. Usually follows abdominal surgery or trauma. Immune compromised [ e.g.Diabetics and IV drug addicts ] are more susceptible. Necrotizing fascitis 3- Necrotizing fascitis :

27. Starts as cellulitis & systemic toxicity. B ut; Characterized by non-blanching erythema, with blisters and frank necrosis of the skin. No definitive margins ( usually requires multiple debridements ). Extensive surgical debridement of the affected area, in combination with high dose penicillines and clindamycin is the appropriate Rx. Starts as cellulitis & systemic toxicity. B ut; Characterized by non-blanching erythema, with blisters and frank necrosis of the skin. No definitive margins ( usually requires multiple debridements ). Extensive surgical debridement of the affected area, in combination with high dose penicillines and clindamycin is the appropriate Rx. Cont.

35. Caused by cl. Perfringens ( mainly ) or cl. Septicum Commonly enter the body through wounds contaminated with soil. Produce exotoxins. It is characterized by progressive rapidly spreading edema. Caused by cl. Perfringens ( mainly ) or cl. Septicum Commonly enter the body through wounds contaminated with soil. Produce exotoxins. It is characterized by progressive rapidly spreading edema. 4- gas gangrene:

36. Rapid myonecrosis it results in swelling, seropurulent discharge, crepitus in subcutaneous tissues, gas production and foul smelling wounds. Other findings: ill looking patient, profound toxemia, tachycardia and in X-ray appearance of gas under skin and in muscles. Rapid myonecrosis it results in swelling, seropurulent discharge, crepitus in subcutaneous tissues, gas production and foul smelling wounds. Other findings: ill looking patient, profound toxemia, tachycardia and in X-ray appearance of gas under skin and in muscles. Cont.

41. Wound debridement, drainage and exposure. Antibiotics (penicillins, clindamycin or metronidazole). *Antibiotics are not effective without aggressive debridement. Wound debridement, drainage and exposure. Antibiotics (penicillins, clindamycin or metronidazole). *Antibiotics are not effective without aggressive debridement. Treatment :

42. Putting the patient in a hyperbaric oxygen chamber may help ( anerobic infection ). Amputation may be required. Putting the patient in a hyperbaric oxygen chamber may help ( anerobic infection ). Amputation may be required. Cont Rx.

43. Caused by cl. tetani as complication of wound contamination. Usually the wound is healed when the symptoms start to appear. Incubation period one to three weeks. * Cl. tetani produces a neurotoxin that stimulates the nerves in spinal cord that leads to muscle spasm. Caused by cl. tetani as complication of wound contamination. Usually the wound is healed when the symptoms start to appear. Incubation period one to three weeks. * Cl. tetani produces a neurotoxin that stimulates the nerves in spinal cord that leads to muscle spasm. 5- Tetanus:

44. The first manifestations include trismus ( lockjaw ), neck and back stiffness. Other manifestations include risus sardonicus ( an anxious look with mouth drawn up ), progressive dysphasia and difficult respiration and reflex convulsions along with intense tonic contractions of body muscles. The first manifestations include trismus ( lockjaw ), neck and back stiffness. Other manifestations include risus sardonicus ( an anxious look with mouth drawn up ), progressive dysphasia and difficult respiration and reflex convulsions along with intense tonic contractions of body muscles. Cont.

45. May result in death due to exhaustion, aspiration or asphyxia. Cont.

49. Rx include wound debridement, penicillin, muscle relaxants, ventilation and nutrition in Intensive care unit. Prophylaxis: Wound care & antibiotics. Vaccination by tetanus immunoglobulin in high risk pts ( passive immunization ). Commence active immunization (T toxoid). Rx include wound debridement, penicillin, muscle relaxants, ventilation and nutrition in Intensive care unit. Prophylaxis: Wound care & antibiotics. Vaccination by tetanus immunoglobulin in high risk pts ( passive immunization ). Commence active immunization (T toxoid). Treatment & prophylaxis

50. In previously immunized pt, if the booster was: > 5 years, the pt needs another booster. < 5 years, no treatment. In previously immunized pt, if the booster was: > 5 years, the pt needs another booster. < 5 years, no treatment. Cont.

51. Cl. Difficile Overtakes normal flora in patients on antibiotics Watery diarrhea, abdominal pain, fever Sigmoidoscopy: membrane of exudates (pseudomembranes) Stool- culture and toxin assay Treatment : Stop offending antibiotic oral vancomycin/ metronidazole, rehydration, Isolate patient. Cl. Difficile Overtakes normal flora in patients on antibiotics Watery diarrhea, abdominal pain, fever Sigmoidoscopy: membrane of exudates (pseudomembranes) Stool- culture and toxin assay Treatment : Stop offending antibiotic oral vancomycin/ metronidazole, rehydration, Isolate patient. PSEUDOMEMBRANOUS COLITIS

54. Normal flora of the skin. The most common cause of surgical site infection in surgical practice. Can cause endocarditis, Abscesses, furuncle (boil), carbuncles. * Antibiotics effective against staph: penicillin, cephalospoin and vancomycin (MRSA). Normal flora of the skin. The most common cause of surgical site infection in surgical practice. Can cause endocarditis, Abscesses, furuncle (boil), carbuncles. * Antibiotics effective against staph: penicillin, cephalospoin and vancomycin (MRSA). Staphylococci

55. Abscess : localized pus collection Treated by drainage & antibiotics. Furuncle : Inflammation of hair follicles or sweat glands treated by drainage & antibiotics. Carbuncle : a large extension of furuncle. Common in diabetics, usually on the back and the neck, treated by drainage & antibiotics. Abscess : localized pus collection Treated by drainage & antibiotics. Furuncle : Inflammation of hair follicles or sweat glands treated by drainage & antibiotics. Carbuncle : a large extension of furuncle. Common in diabetics, usually on the back and the neck, treated by drainage & antibiotics.

57. Furunculoisis

66. paronychia

75. Aerobic opportunistic bacteria that cause skin infections, but also can cause lethal infections. It enter the body through minor skin. abrasions, ventilator tubes, urinary catheter, I.V. lines etc … Treatment : aminoglycosides, piperacillin, ceftazidime. Aerobic opportunistic bacteria that cause skin infections, but also can cause lethal infections. It enter the body through minor skin. abrasions, ventilator tubes, urinary catheter, I.V. lines etc … Treatment : aminoglycosides, piperacillin, ceftazidime. Pseudomonas

76. Important complication of G.I. & biliary surgery. Clinical feature : abdominal pain tenderness fever & leukocytosis. Investigation : X-ray, ultrasound, CT (the most useful ). Treatment :drainage (surgical versus radiological ) & broad antibiotics. Important complication of G.I. & biliary surgery. Clinical feature : abdominal pain tenderness fever & leukocytosis. Investigation : X-ray, ultrasound, CT (the most useful ). Treatment :drainage (surgical versus radiological ) & broad antibiotics. Intra - abdominal abscess

80. . Infection of apocrine sweat glands. axilla, groin, perineum, any skin fold :TREATMEANT. Single abscess treated by I&D. Doxycycline 100mg BID. Excision with STSG (15%). Infection of apocrine sweat glands. axilla, groin, perineum, any skin fold :TREATMEANT. Single abscess treated by I&D. Doxycycline 100mg BID. Excision with STSG (15%) Hydradenitis suppurativa

84. 1- Clean wound : surgery done through clean tissue plains, no need for prophylaxis except for high risk group. Ex: thyroid, breast, hernia surgeries. 2- Clean/contaminated : surgery with suspesion of infection. Ex: cholecystectomy, urinary tract surgery, etc … (entering body cavities) prophylaxis is advisable. 1- Clean wound : surgery done through clean tissue plains, no need for prophylaxis except for high risk group. Ex: thyroid, breast, hernia surgeries. 2- Clean/contaminated : surgery with suspesion of infection. Ex: cholecystectomy, urinary tract surgery, etc … (entering body cavities) prophylaxis is advisable. Classification of wounds

85. 3- Contaminated : surgery where microorganism are definitely present. ex: bowel surgery. Therapeutic antibiotics is advisable. 4- Dirty : surgery through well established infection ex: abscess surgery. the use of antibiotic is considered to be of therapeutic nature. 3- Contaminated : surgery where microorganism are definitely present. ex: bowel surgery. Therapeutic antibiotics is advisable. 4- Dirty : surgery through well established infection ex: abscess surgery. the use of antibiotic is considered to be of therapeutic nature. Cont.

88. . 38% of all surgical infections. Infection within 30 days of operation. Infection within 1 year if prosthetic device used.. 38% of all surgical infections. Infection within 30 days of operation. Infection within 1 year if prosthetic device used. Surgical site infections (SSI)

90. Classification: Superficial SSI: skin & subcutaneous plane (47%) Deep SSI: subfascial and muscle plane (23%) Organ/ space SSI: intra-abdominal, other spaces (30%) Staph. aureus- most common organism E coli, Entercoccus, B fragilis Classification: Superficial SSI: skin & subcutaneous plane (47%) Deep SSI: subfascial and muscle plane (23%) Organ/ space SSI: intra-abdominal, other spaces (30%) Staph. aureus- most common organism E coli, Entercoccus, B fragilis Surgical site infection (SSI)

91. Risk factors. age. malnutrition. obesity. Immune compromised. poor surgical technique. prolonged surgery. preoperative shaving. type of surgery Risk factors. age. malnutrition. obesity. Immune compromised. poor surgical technique. prolonged surgery. preoperative shaving. type of surgery Surgical site infection (SSI)

92. Diagnosis: Sup.SSI- erythema, oedema, discharge and pain RX: antibiotics & remove clips and drainage of pus (ClS). Deep infections- no local signs, fever, pain, hypotension. need investigations. Treatment: surgical / radiological intervention. Diagnosis: Sup.SSI- erythema, oedema, discharge and pain RX: antibiotics & remove clips and drainage of pus (ClS). Deep infections- no local signs, fever, pain, hypotension. need investigations. Treatment: surgical / radiological intervention. Surgical site infection (SSI)

94. Pre-op: Treat pre-existing infection Improve general nutrition Shorter hospital stay Pre-op. shower Hair removal -shaving vs clipping Intra-operative: Antiseptic technique Good surgical technique Normothermia Post-operative: Wound dressing in 48-72 hours Early drain removal Blood sugar control Pre-op: Treat pre-existing infection Improve general nutrition Shorter hospital stay Pre-op. shower Hair removal -shaving vs clipping Intra-operative: Antiseptic technique Good surgical technique Normothermia Post-operative: Wound dressing in 48-72 hours Early drain removal Blood sugar control Prevention of SSI

95. Chemotherapeutic agents directed towards micro-organisms. They are either synthetic or semi-synthetic. Penicillin has a wide safety margin, Inhibits cell-wall synthesis. Hyper sensitivity event. is the main side effect but luckily it is a rare Therefore skin sensitivity test is a must before intravenous therapy. Chemotherapeutic agents directed towards micro-organisms. They are either synthetic or semi-synthetic. Penicillin has a wide safety margin, Inhibits cell-wall synthesis. Hyper sensitivity event. is the main side effect but luckily it is a rare Therefore skin sensitivity test is a must before intravenous therapy. ANTIBIOTICS

96. Gentamycine:  Is the main aminoglycoside.  It inhibits ribosome synthesis.  Effective in Gram-ve bacteria. eg: psudomonas and E.coli. side effects includes ; ototoxicity and nephrotoxicity. It has a narrow safety margin. Gentamycine:  Is the main aminoglycoside.  It inhibits ribosome synthesis.  Effective in Gram-ve bacteria. eg: psudomonas and E.coli. side effects includes ; ototoxicity and nephrotoxicity. It has a narrow safety margin.

97. Tetracycline  Is a wide spectrum bacteriostatic antibiotic ( gram+ve & gram-ve ).  It alters the ribosome synthesis in bacteria.  Main side effects includes: - teeth discolouration - risk of super infection Tetracycline  Is a wide spectrum bacteriostatic antibiotic ( gram+ve & gram-ve ).  It alters the ribosome synthesis in bacteria.  Main side effects includes: - teeth discolouration - risk of super infection

98. Amphotericin B  is an anti fungal which acts by impairing DNA synthesis.  It is a hepatotoxic and nephrotoxic in high doses like gentamycine. (narrow safety margine )  This antibiotic should always be given with frequent pre and post dose serum level assessment. Amphotericin B  is an anti fungal which acts by impairing DNA synthesis.  It is a hepatotoxic and nephrotoxic in high doses like gentamycine. (narrow safety margine )  This antibiotic should always be given with frequent pre and post dose serum level assessment.

99. Antibiotic which is given to patients bfore surgery or invasive procedure in order to prevent infection. A high serum level of the antibiotic is essential just before starting the procedure. It is usually given intravenously or one hour intramuscularely before the surgery. Antibiotic selection depends on common bacteria in the operative site. It is usually given in clean contaminated and contaminated procedures. Antibiotic which is given to patients bfore surgery or invasive procedure in order to prevent infection. A high serum level of the antibiotic is essential just before starting the procedure. It is usually given intravenously or one hour intramuscularely before the surgery. Antibiotic selection depends on common bacteria in the operative site. It is usually given in clean contaminated and contaminated procedures. Prophylactic antibiotic

100. Asepsis - sterilization Wet heat in an autoclave at 121° c for 20 minutes, or at a higher temperature for a shorter time (HTST) to provide an equivalent exposure. Dry heat in a hot-air oven at 160° c for one hour. Irradiation under strictly controlled conditions (used predominantly in industry). Special sterilizing chemicals, liquids or gases, such as formaldehyde, glutaradehyde or ethylene oxide, under strictly controlled conditions. - disinfection - Antisepses Asepsis - sterilization Wet heat in an autoclave at 121° c for 20 minutes, or at a higher temperature for a shorter time (HTST) to provide an equivalent exposure. Dry heat in a hot-air oven at 160° c for one hour. Irradiation under strictly controlled conditions (used predominantly in industry). Special sterilizing chemicals, liquids or gases, such as formaldehyde, glutaradehyde or ethylene oxide, under strictly controlled conditions. - disinfection - Antisepses

101. Thank you !! Now an example of exam questions:

102. Example of exam. MCQ A 30 years old house-maid has a puncture wound in her right hand 5 days ago, now she is presenting with painful,red,hot and swallen hand. What is the most likely diagnosis? a. Carbuncle. b. Cellulitis. c. Lymphangitis. d. Erysipelas. A 30 years old house-maid has a puncture wound in her right hand 5 days ago, now she is presenting with painful,red,hot and swallen hand. What is the most likely diagnosis? a. Carbuncle. b. Cellulitis. c. Lymphangitis. d. Erysipelas.

103. Example of exam. MCQ A 30 years old house-maid has a puncture wound in her right hand 5 days ago, now she is presenting with painful,red,hot and swallen hand. What is the most likely diagnosis? a. Curbuncle. b. Cellulitis. c. Lymphangitis. d. Erysipelas. A 30 years old house-maid has a puncture wound in her right hand 5 days ago, now she is presenting with painful,red,hot and swallen hand. What is the most likely diagnosis? a. Curbuncle. b. Cellulitis. c. Lymphangitis. d. Erysipelas.

104. MCQ Example : A 25 years old male patient admitted via emergency room complaining of fever, lower abdominal pain and diarrhoea.He had appendectomy 7 days ago. His s.site is clean. What is the most likely Dx ? a.Gastro- enteritis. b.Urinary tract infection. c.Pelvic collection (abscess). d.Diverticulitis. MCQ Example : A 25 years old male patient admitted via emergency room complaining of fever, lower abdominal pain and diarrhoea.He had appendectomy 7 days ago. His s.site is clean. What is the most likely Dx ? a.Gastro- enteritis. b.Urinary tract infection. c.Pelvic collection (abscess). d.Diverticulitis.

105. MCQ Example : A 25 years old male patient admitted via emergency room complaining of fever, lower abdominal pain and diarrhoea.He had appendectomy 7 days ago. His s.site is clean. What is the most likely Dx ? a.Gastro- enteritis. b.Urinary tract infection. c.Pelvic collection (abscess). d.Diverticulitis. MCQ Example : A 25 years old male patient admitted via emergency room complaining of fever, lower abdominal pain and diarrhoea.He had appendectomy 7 days ago. His s.site is clean. What is the most likely Dx ? a.Gastro- enteritis. b.Urinary tract infection. c.Pelvic collection (abscess). d.Diverticulitis.