INFLAMATION,INFECTION,AND USE OF ANTIBIOTICS IN SURGERY

DR AMAEFULA, E. TEMPLE
MBBS,FWACS,FAOI,
FELLOWSHIPS IN SPINE, TUMOUR AND JOINT
REPLACEMENT SURGERY
 INFLAMMATION
• Vascular and cellular response to injury
mediated by chemical factors derived from
plasma and cells triggered by an inflammatory
stimulus clinically manifesting as -
– Rubor
– Tumor
– Calor
– Dolor
– Functio laesa.
 Cardinal signs of (acute)
inflammation

• Rubor = redness
• Tumor = swelling
• Calor = heat
• Dolor = pain
(described by Celsus 1st. Century AD)

• Functio laesa = loss of function

(added by R. Virchow)

Cellulits = acute skin infection commonly caused

by Streptococcus pyogenes or Staphylococcus
aureus
 INFLAMMATION
• It is characterized by vascular reaction leading
to fluid and leukocyte accumulation in the
extra vascular tissues

• It helps to
– Dilute
– Destroy
– Wall off injurious agents
– sets in motion events that lead to healing and
reconstitution of damaged tissues
 INFLAMMATION
• Two types
– Acute
• immediate and early response
• Characterised by
– Vasodilatation ----
– Increased vascular permeability
– Emigration of leukocytes

– Chronic
• Lasts longer
• Associated histologically with
• Presence of lymphocytes and macrophages,
• Proliferation of blood vessels,
• Fibrosis and Tissue necrosis
 INFLAMMATION
EXUDATE TRANSUDATE

INFLAMATORY EXTRAVASCULAR FLUID PLASMA ULTRA FILTRATE FROM

HYDROSTATIC IMBALANCE

HIGH PROTEIN LOW PROTEIN(MAINLY ALBUMIN)

SPECIFIC GRAVITY>1.020 SPECIFIC GRAVITY<1.012

MORE CELLS NO CELLS

 INFLAMMATION
• EDEMA
– Excess fluid in interstitial or serous cavity can be
exudate or transudate
– PUS
– Purulent exudate inflamatory in nature rich in
leukocytes
Different morphological patterns of acute inflammation can be found depending on the
cause and extent of injury and site of inflammation

Serous inflammation Purulent inflammation

Fibrinous inflammation ulcers

 Acute inflammation involves:
alteration of vascular caliber
following very brief vasoconstriction
(seconds), vasodilation leads to increased
blood flow and blood pooling creating
redness and warmth (rubor and calor)
changes of microvasculature
increased permeability for plasma
proteins and cells creating swelling
(tumor). Fluid loss leads to concentration
of red blood cells and slowed blood flow
(stasis)
emigration of leukocytes from
microcirculation
due to stasis and activation leads
migration towards offending agent
 Vascular changes and fluid leakage during acute inflammation lead to Edema in a
process called Exudation

Transudate
•result of hydrostatic
or osmotic imbalance
•ultrafiltrate of plasma
•Low protein content
•specific gravity < 1.015

Exudate
•result of inflammation
•vascular permeability
•high protein content
•specific gravity >1.020
 Outcome of acute inflammation

• Complete restitution

• Abscess formation (encapsulation and pus)

• Chronic inflammation

• Healing with scar formation

 SURGICAL INFECTIONS
• Infections (contamination with local or
systemic signs) associated with anatomical or
mechanical problems that must be resolved by
surgical operation or other invasive procedure

• With Developments in anaesthesia more

surgery was performed but majority were
infected.
 SURGICAL INFECTION

• HISTORICAL REVIEW
– Principles of asepsis
• Ignaz semmelweis 1847

– Principles of antisepsis
• Joseph Lister 1867

– Nature of putrefaction
• Louis pasteur

– Antibiotics(Penicillin)
• Sir Alexander Fleming
 Classification of surgical infection according to risk factors
DEFINITION UNACCEPTABLE RISK RATE AT 30
DAYS

CLEAN NON TRAUMATIC, NO >1.5%

BREAK IN TECHNIQUE
RESPIRATORY,INTESTINAL,
AND GASTROINTESTINAL TRACT
NOT ENTERED
CLEAN CONTAMINATED GENITO URINARY,GASTRO >3%
INTESTINAL TRACT ENTERED
WITHOUT SIGNIFICANT
SPILLAGE,
OROPHARYNX,VIRGINA,OR NON
INFECTED GENITO URINARY OR
BILIARY TRACT ENTERED,
MINOR BREAK IN TECHNIQUE

CONTAMINATED MAJOR BREAK TECHNIQUE >5%

TRAUMATIC WOUND
GROSS SPILLAGE FROM G.I,
ENTRANCE INTO G.U,BILLIARY
TRACT WITH INFECTION
 SURGICAL INFECTION

• CAUSES OF WOUND INFECTION

– When ever microbial inoculum overcome host
defense mechanism and establish progressive
growth, then wound infection occur

– Host defence interact with pathogen factors

– Bacterial Factors
– Virulence or Infectivity
» Certain bacterial surface components inhibit phagocytosis
e.g Capsules of Klebsiella and pneumococcus
» Act as endotoxins eg Enterobacteria
» Exotoxins eg clostridia
– Dose
» Bacteria contamination of > 105 is enough to establish
infection
 SURGICAL INFECTION
• Local wound factors
– whatever inhibits local defense mechanism for
clearing bacteria will enhance infectivity
– what ever interferes with ability of phagocyte to
directly contact and kill bacteria potentiate wound
infection e.g. presence of foreign bodies eg
sutures

• Lack of accurate approximation of tissues

• Strangulation of tissues with sutures
• Good surgical technique can minimize this
 SURGICAL INFECTION
• Age
– infection is common in the very young and very old

• Causes of reduced blood flow to surgical incision

– Vaso-occlusive states
– Hypovolaemic shock
– Vasopressors,vasoconstrictors
– Conditions that reduce vascular reactivity eg
uraemia, old age, high dose steroid
– Cancer, trauma, diabetes
 SURGICAL INFECTION
• PREVENTION OF WOUND INFECTION
– Sources of bacterial contamination
– Exogenous:from breaks iin aseptic techniques in
operating theatr
– Endogenous :from breaks in patients skin and
contaminated hollow viscus
– main source of infection in all wounds except
clean wound
 SURGICAL INFECTION
• AVOIDING BACTERIAL CONTAMINATION
– EXOGENOUS
• ENVIRONMENTAL FACTORS
– Engineering and theatre design
» Use of UV light in decontamination of OR
» Laminar flow/high flow terminal ventilation system
» Positive theatre pressure in the OR
– BEHAVIOURAL CHANGES IN THE OR STAFF
» Reduced in and out traffic during operation
» Reduced activity and talking in OR
» Controlled No. of OR staff
– STRICT MONITORING OF STERILIZATION PROCESS
 SURGICAL INFECTION
• AVOIDING BACTERIAL CONTAMINATION
– EXOGENOUS
• Patient factor
– Patients on long term hospital admission have increased
resident organisms on skin
– Pre-op preparation will reduce bacterial contamination
» Pre-op antibacterial shower
» Removal of hair with clippers
» Skin preparation
» Draping
• Operation team discipline
– Use of clean scrub suits, caps, masks
– Scrubbing before surgery
– Gowning and gloving techniques
 SURGICAL INFECTION

• ENDOGENOUS CONTAMINATION
– Pre-op bowel preparation
– Use of appropriate surgical techniques in isolating
contaminated bowel
– Antibiotic wound irrigation
– Surgical techniques
• Meticulous wound care and tissue handling
• Removal of devitalized tissues
• Debridement and washing of wounds and leaving wounds open
for delayed primary closure
• Use of monofilament sutures
• Elimination of dead space and prevention of haematoma
• Use of closed suction drains with removal after 48 hours
• Appropriate skin closure without overlap
 SURGICAL INFECTION
• SYSTEMIC FACTORS
– Systemic conditions e.g. leukemia, DM, uraemia,
prematurity, burns, old age, etc
– Social consideration
– 50% reduction observed in accurate continued surveillance
and communication with the surgeon
– Immune therapy
• Active /passive immunization for tetanus and rabies
– Prophylactic use of antibiotics and chemotherapeutic
agents
• Risk and benefit are to be weighed
• Indiscriminate use may lead to development of resistance strain in
hospital environment, secondary or superimposed infection, or
may mask signs & symptoms of established infection
 SURGICAL INFECTION
• Prophylaxis not indicated in
– clean surgical op’s
– Surgeries not requiring insertion of foreign bodies or implants
– Not a substitute for good surgical techniques
• Prophylactic antibiotics must achieve therapeutic blood level at
time of surgical incision
• Indications for antibiotic prophylaxis
– Accidental open wounds
– Penetrating injuries of hollow abdominal viscus
– Resection/anastomosis of colon or small bowel
– Emergency operation in the presence of active infection
– Surgery on damaged heart valves
– Vaginal and abdominal hysterectomies
– Prosthetic implant procedures
– Extremities amputation
– Open fractures
 SURGICAL INFECTION

• General surgical infections

– Common organisms include
• Staphylococcus
• Streptococcus
• Pneumococcus
• H. influenzae
• gram –ve organisms
 SURGICAL INFECTION

• Staphylococcus
– Gram +ve
– Two forms
• Staph pyogenes (aureus)
– Coagulase +ve
– Involved in hospital infections causing carbuncles,
boils, stye, septic hands breast abscess,
osteomyaelitis, etc
• Staph albus
– Coagulase –ve
– May cause low grade inflammation
 SURGICAL INFECTION

• Streptococcus
– Three forms
• α- hemolytic
• β-hemolytic
• Anaerobic cocci
– All gram +ve
– Produce various toxins
• Hemolysin – lyse rbc
• Leucocidin – kills PNL’s
• Fibrinolysin – lyses fibrin
• Erythrogenic toxin – causes skin erythema
• Hyaluronidase – digests collagen aiding infection spread
• Deoxyribonuclease – splits DNA
 SURGICAL INFECTION
• α- haemolytic streptococcus
– Produce xteristic clear zone of haemolysis
surrounding colonies in blood agar
– Lancefield group A strain cause 90% human
infection
• tonsilities,otities media scarlet fever

• α- Haemolytic streptococcus(strept viridans)

– Produce greenish haemolysis surrounding colonies
– Cause tonsilitis , oral infections
 SURGICAL INFECTION
• Others
– E. coli, Pseudomonas, Proteus org
• Described as coliforms, G-ve rods, inhabit large bowels
• Non lactose fermenting are more pathogenic
– less latcose fermenting predominate in surgical infection

– [Link]:
• Important because has developed resistance
• produces powerful endotoxin

– Pseudomonas pyocyanea
• G-ve, low pathogenicity, form bluish green pus with xteristic
odour
• has powerful endotoxin
 SURGICAL INFECTION
• Proteus vulgaris
– Secondary invader
– infect urinary tract,
– split urea into ammonia and CO2 making urine alkaline and
ppt phosphate deposit

• Klebsiella org
– Cause hepatic abscess, pneumonic lession, wound infection

• H. influenzae
– URTI, Otitis media, sinusitis, etc
 SURGICAL INFECTION
• EXAMPLES OF SURGICAL INFECTIONS
– Soft tissue infection
• Subcutaneous abscess
• xterised by necrotic center without blood supply
• contains debris from local tissue, dead and dying WBC ,
blood component, plasma,bacteria
• This semi fluid liquid is surrounded by vascularised
inflamed tissue. Eg felon , breast abscess, perirectal
abscess

• Cellulitis
– Soft tissue infection with intact blood supply, viable tissues with
marked acute inflamatory response, endothelial leakage and
interstitial edema
 SURGICAL INFECTION
• Necrotizing soft tissue infections
– Mainly caused by clostridial organisms- [Link], c .
novyi, [Link]

• Non clostridia Necrotising Infection: α-Haemolytic

streptococcus, [Link]
– Xterised by absence of clear local boundaries or palpable limits
– marked by a layer of necrotic tissue not walled off by inflamatory
reaction.
– Overlying skin is relatively normal

• Clostridial infection involve underlying muscle(myonecrosis or

gas gangrene)
 SURGICAL INFECTION

• Non clostridial,(and some clostridial necrosis)

spread in sub cutaneous fascia between skin
and deep muscular fascia
– Clinical features
• Marked haemodynamic response
• Failure of response to conventional non op treatment
• Apparent cellulitis ecchymosis, bullae, dermal gangrene
• Crepitus
 SURGICAL INFECTION

• Treatment
– Clostridial myonecrosis
• excision, amputation
– Non clostridial
• wide excision

– Others
• Non Surgical infection in a surgical patient
– UTI in a catheterised patient
– lower respiratory tract infection in a patient with intubation
• Prosthetic device associated infection
• HIV infection
 SURGICAL INFECTION

• Systemic effects of infection

– Bacteraemia
– Septicaemia
– Pyaemia

• Clinical features of surgical infection

– fever, - chills
– Rigors - malaise
– Weakness - anxiety
– Confusion - delirium

• Laboratory investigation
– Fbc
– blood cultures
 SURGICAL INFECTION

• Principles of treatment
– General measures
• assessment and treatment of nutritional , immune
deficiency states
• nursing care
• antibiotics
– Local measures
• rest elevation
– surgery
 SURGICAL INFECTION
• Specific acute infection
– Tetanus
– Gas gangrene
– Anthrax
– Rabies

• Specific Chronic infections

– Tuberculosis
– Actinomycosis
– Yaw
– Gonorhoea
– Syphilis
– Lymphogranuloma venereum
– Granuloma inguinale
 SURGICAL INFECTION
• Surgical infestation
– FILARIAL
• Filariasis: wuchereria bancrofti,brugia malayi;mosquito trasmission
– Early Local reaction:funiculities,epididymo orchities,lymphangitis,adenities
– Late obstruction:lymphoedema,hydrocoele,lymhocoele, adenolymphocoele
– Treatment :medical DEC Diethyl carbamazine,ivermectin
– surgery
• Onchocercisis
– onchocerca volvulus;transmission simolium damnosum
– Clinical features include generaized puritus of skin, subcutaneous nodules, ocular
lesions, lymphoedema,
• Treatment - ivermectin, surgery

– DRACUNCULOSIS dracunculus medinesis(guinea worm)

• intermediate host - cyclops.
• Clinical feature
– Pruritus - urthicaria
– granuloma at groin and trunk
 SURGICAL INFECTION
• Schistosomiasis
– Haematobium
– Mansoni
– japonicum
 Antibiotics

• Antibiotics are antimicrobial agents capable of

causing damage to bacteria without harming
normal tissues
– they were original product of microbes originally
though can now be synthesized

• Together with synthetic agents eg

nitrofurantoin,sulphonamides form
antimicrobial agents
– can be bacteriocidal or bacteriostatic in mechanism
of action
– They are used for prophylaxis or therapeutically
 Antibiotics
• Principles of use
– Adjunct,not substitute for surgery
– Mask signs of infections therefore given after diagnosis
made
– Most effective and appropriate combination given in
insufficient doses and adequate duration
– Bacteriostatic agents eg tetracyclene,chloramphenicol etc
slow and stabilise bacteria growth,bacteriostatic agents act
on unstable cell wall therefore both should not be mixed
– Good choice should avoid side effect
– Physiological deficiencies eg anaemia
,dehydration,hypoproteinemia hypogycaemia should be
treated