The document discusses surgical infections, including their objectives, pathophysiology, classification, and management. It covers various types of infections that may appear spontaneously or post-operatively, such as cellulitis, abscesses, boils, and carbuncles. Key points include the role of patient, bacterial, local, and environmental factors in infections. Surgical site infections are classified as acute or chronic, and treatment involves antibiotics, incision and drainage, wound care, and controlling underlying conditions. Complications like sepsis, gangrene and death are also addressed.

1. SURGICAL INFECTIONS
• Contents:
objectives
Introduction
Pathophysiology
Classification
management
1

2. objectives
1.To have knowledge of scientific bases of
surgical infections
2.To be capable of diagnose and treat pts.
with surgical infections
2

3. INTRODUCTION
• Since the time surgery has evolved as a
specialty and despite the existence of newer
generation of antibiotics, infection has been
recognized as a well known enemy of
surgeons and still continues to be one of the
major causes of morbidity and mortality.
• So, it is important to diagnose and treat
infections as early as possible.
3

4. PATHOPHYSIOLOGY
The clinical features and the coarse of an
infection depend on an interplay
between the following factors :
1. patient’s(host) factors
2. bacterial factors
3. local factors
4. environmental factors
4

5. PATIENT’S FACTORS
• are explained by :
1. defense mechanism of the
pt.(host)
2. general factors of the host
5

6. DEFENSE MECHANISM OF
THE HOST
• In this mechanism of combating
infections, the following
defenses are used :
1. natural defense
2. artificial defense
6

7. NATURAL DEFENSE
A. the intact epithelium of the skin
respiratory, alimentary and urinary tracts
B. local tissue reaction of acute
inflammation(important means of
containing and destroying the invading
organism)
C. immunological defenses with the
production of specific antibodies in
response to foreign protein.
7

8. ARTIFICIAL DEFENSE
REINFORCES THE NATURAL DEFENSE AND CAN
BE FORMED BY:
1. ACTIVE IMMUNIZATION: using killed micro-
organisms such as TAB vacc. for typhoid or
• Attenuated living organisms(BCG. Vacc for TB.)
• Inactivated toxins (toxoids) such as formalin
inactivated Tetanus toxoids).
2. PASSIVE IMMUNIZATION :employs antiserums
produced by injecting the organism or toxins into an
animal(tetanus antitoxin & diphtheria)
3. CHEMOTHERAPEUTIC AGENTS : which act by
bacteriostatic / bactericidal mechanisms and their
effects depend on :
• Adequate blood supply
• Absence of walling off of the bacteria in a cavity
surrounded by ch. Inflammatory tissues.
• Absence of sloughed tissues 8

9. GENERAL FACTORS OF
THE HOST
1. age :extreme ages due to immaturity
/senescent resistance
2. nutritional state of the host
3. anemia
4. severe systemic diseases : DM. renal
failure, vascular occlusive diseases
cancer, immunodeficiency.etc.
9

10. BACTERIAL FACTORS
Depend on :
1. kind of the bacteria : streptococci and
clostridia cause early and severe infections.
2. number of the inoculated bacteria
3. virulence of the bacteria :
• toxicity :(endotoxins / exotoxins)- power of
the organism to injure the host’s tissues.
• invasiveness :the ability to attack and
spread in the body.
• the bacterial ability to resist phagocytosis
and intracellular destruction(capsule of
klebsiela and streptococcal pneumonia)
10

11. LOCAL FACTORS
1. Inhibition of local defense mechanisms for
clearing bacteria(any thing that interferes with
the ability of phagocytosis)
2. presence of dead tissues
3. presence of seroma
4. presence of foreign body
5. local decrease of O2 tension
• low blood flow
• systemic hypoxemia.
11

12. ENVIRONMENTAL FACTORS
• These factors mostly influence on
hospitalized patients for surgical procedures
• Despite their numbers, some of them are :
1. ward factors
2. operation theatre factors
3. operating room team factors
4. sterilization technique factors
5. surgical technique factors
6. anesthetic ‘s accessories factors
7. postanaesthetics recovery room factors etc.
12

13. CLASSIFICATION OF
SURGICAL INFECTIONS
I. infections which appear
spontaneously and need surgery
for their resolution
II. infections which appear after
surgical procedures(postoperative
infections)
13

14. SURGICAL INFECTIONS WHICH
APPEAR SPONTANEOUSLY AND
NEED SURGEY FOR RESOLUTION
ARE CLASSIFIED IN:
• acute infections
• chronic infections
14

15. ACUTE INFECTIONS
• SOME OF THEM ARE :
1. cellulitis
2. abscess
3. boils
4. carbuncle
5. Ludwig's angina
6. gas gangrene
7. tetanus
8. anthrax
15

16. CELLULITIS
• DEFINITION :is a spreading acute
inflammation of connective tissues and
fascial planes in different sites.
• CAUSE :B-hemolytic streptococcus by
producing enzymes (hyaluronidase /
streptokinase)
• MODE OF ENTERY :
1.graze /scratch
2.injury
3.bites (snakes / scorpion )
16

17. FACTORS:
1. DM.
2. low body resistance
sites :
1. subcutaneous tissues(limbs, face, scrotum) – is very
common
2. pelvic
3. retroperitoneal
4. perinephric
5. pharyngeal
6. intra-orbital
17
PRECIPITATING FACTORS OF CULLULITIS &
SITES OF FREQUENT APPEARANCE

18. CLINICAL FEATURES OF
CELLULITIS
• swelling
• dusky redness and itching of the affected
area
• stretched and shiny skin
• severe pain, fever and toxemia
• suppuration, gangrene and sloughing ( in
advanced cases)
18

19. TREATMENT OF CELLULITIS
1. immobilization / elevation of the affected
part
2. bed rest
3. antibiotics and analgesics/antipyretics
4. cold compress
5. short wave diathermy
6. control of the underlying disease (Dm,
debility)
7. Anti-snake’s venom (if snake bite)
19

20. COMPLICATIONS OF
CELLULITIS
1. abscess
2. cutaneous gangrene
3. toxemia and septicemia
4. DKA. (in diabetic pts.)
20

21. ABSCESS
• DEFINITION : localized collection of pus
• CAUSE : staphylococcus
• CLASSIFICATION :
1. pyogenic
2. pyaemic
3. cold abscess
(Tb,actinomycosis,leprosy,madura
foot)
21

22. SOURCE OF ABSCES
1. direct inoculation by external wound
2. lymphatic
3. haematogenous (from distant focus
of infection : tonsilitis,caries,apical
abscess etc.
4. complicated cellulitis
22

23. CLINICAL FEATURES OF AN
ABSCES
A. GENERAL :- throbbing pain at the site due
to pressure on nerve ends, fever, chills and
rigor
B. LOCAL :
• calor = heat
• rubor = redness
• dolor = pain (tender)
• tumor = swelling / edema
• loss of function
• flactuation (if superficial ,no in deep)
23

24. RX. OF ABSCES
1. incision and drainage preferably
under GA.
2. culture and sensitivity of the pus
3. antibiotic(cloxacillin) 5-7days
4. analgesics /antipyretics
5. wound care
24

25. DIFFERENTIAL DIAGNOSIS
OF AN ABSCES
1. Cellulitis
2. aneurism
3. soft tissue sarcoma
25

26. DIFFERENCE BETWEEN
CELLULITIS & ABSCES
CELLULITIS ABSCES
• no edge has edge
• no limit has limit
• no pus has pus
• no fluctuation is fluctuant
26

27. PYAEMIC ABSCES
• Cause :pus producing micro-organism in
circulating blood with systemic effect of
sepsis
• Predisposing factors :
1. Dm.
2. Chemotherapy
3. Radiotherapy
27

28. CLINICAL FEATURES & RX. OF
PYAEMIC ABSCESS
CLINICAL FEATURES:
• non reactive abscess
• multiple and deeply seated
• tenderness is minimal
Rx. :
1. Iv. Antibiotics
2. analgesics/antipyretics
3. multiple incisions and drainage
28

29. COLD ABSCESS
Are chronic abscess due to chronic
diseases, like Tb, actinomycosis,
leprosy and Madura foot
Generally, they solve by medical Rx.
Accordingly
Surgical intervention is needed only when
they become resistant.
29

30. BOILS
Definition : small abscess of hair follicle and its
gland, on hairy part of the body.
Cause : staphylococcus aureus
Source :
• friction
• macerated and dirty skin by sweat
• infected sebaceous / retention cysts
Precipitating factors :
• Dm
• poor immunity
• lack of hygiene
30

31. COMMON SITES OF BOILS
1. face
2. back of the neck
3. axilla
4. gluteal region
5. external auditory meatus
31

32. CLINICAL FEATURES OF
BOILS
• painful indurated swelling
• centered by hair
• edematous around
• softening and pustule on its center
32

33. RX. OF BOILS
1. if early and no pus :
• antibiotics (cloxacillin)
• analgesics /antipyretics
• ultraviolet light
• short wave diathermy
2. if late and pus formed :
• antibiotics and analgesics
• incision & drainage under LA
• wound care
• Rx. of the underlying disease
33

34. COMPLICATIONS OF BOILS
1. cutaneous necrosis
2. pyaemia / septicemia
3. cavernous sinus thrombosis (face, eye -
lids)
34

35. CARBUNCLE
DEFINITION : infective necrosis of the
subcutaneous tissues, discharging pus on
the skin through multiple sinuses (sieve
like openings/ cribiform appearance)
cause : staphylococcus aureus
35

36. PREDISPOSING FACTORS &
COMMON SITES FOR
CARBUNCLE
predisposing factors
– Dm.
– poor immunity
– Radiotherapy
common sites :
– nape of the neck
– back
– shoulder
– dorsum of the hands
36

37. CLINICAL FEATURES OF
CARBUNCLE
• hx. of predisposing factors
• severe pain
• severe fever, chills and rigor
• brawny swelling surrounded by induration
• dusky overlying skin with pus discharging
sinuses (openings)
37

38. RX. OF CARBUNCLE
A) if early :solves in 10-15 days by
• control of the underlying disease
• iv. antibiotics
• analgesics/antipyretics
• short wave diathermy
• protective saline dressings to reduce edema
b)if late (after pus formation):
• cruciate incision & debridement under GA/LA
• culture & sensitivity of the pus
• antibiotics
• analgesics/antipyretics
• wound care
38

39. COMPLICATIONS OF
CARBUNCLE
1. DKA.
2. extensive skin necrosis
3. septicemia / toxemia
39

40. LUDWIG’S ANGINA
DEFINITION : cellulitis of submental and
submandibular region with inflammatory
edema of the mouth.
causes : streptococcus and anaerobes
precipitating factors :
– caried tooth
– cancer of the oral cavity
– calculi in the submandibular gland
– chemotherapy
– cachexia
– DM.
40

41. CLINICAL FEATURES OF
LUDWIG’ ANGINA
• submental & submandibular swelling
(brawny edema)
• edema of the floor of the mouth
• high grade fever & toxicity
• putrid halitosis
• trismus
41

42. RX. & COMPLICATIONS OF
LUDWIG’S ANGINA
RX. :
1. admission & rest
2. appropriate iv antibiotics
3. analgesics/antipyretics
4. iv. fluids
5. feeding through NG. tube
6. if conservative Rx. failed : I-D under GA and
wound care
complications :
1. mediastinitis/septicemia
2. edema of the glottis
42

43. GAS GANGREN
DEFINITION : necrotizing infection of
muscle(myonecrosis) and soft tissue.
other names:
• clostridia myositis
• clostridial myonecrosis
• infective gangrene of the muscle
43

44. CAUSES (PATHOGENESIS) OF
GAS GANGREN
1. clostridium Welchii (60% and
commonest)
2. clostridium septicum
3. clostridium oedematiens
4. clostridium hystolyticum
-These organisms are anaerobes,
sporforming, gas producing and
secretors of powerful endotoxins and
hyaluronidase
44

45. SOURCE & PREDISPOSING
FACTORS OF GAS GANGREN
SOURCE :
• exogenous : manured /cultivated soil
• endogenous : normal intest. / feces
Predisposing factors :
• presence of soil, clothing, bullets, glass pieces
and other fbs. in wound
• anoxia due to crashing of the arteries
• dead and necrotic tissues
• hematoma
45

46. CLINICAL FEATURES OF GAS
GANGREN
HAS 24hrs. OF INCUBATION PERIOD
GENERAL FEATURES :
• anxious and alert pt.
• toxic and acutely sick
• tachycardia
• hypotensive
• anorexic / vomiting
• low grade fever
LOCAL FEATURES :
• sever pain and edema of the wound
• offensive watery brown discharge from the wound
• crepitation to palpation and non contracting dark red
fragile muscle
• khaki colored skin due to haemolysis
46

47. RX. OF GAS GANGREN
• is based on :
1. prophylactic Rx.
2. curative Rx.
47

48. PROPHYLACTIC RX. OF GAS
GANGREN
• debridement of wounds
• do not suture wounds of long hrs. duration
• prophylactic use of antibiotics (crit.
penicillin for 7 days
• judicious and minimal use of tourniquets
• gentle and effective application of plaster
casts
48

49. CURATIVE RX. OF GAS
GANGREN
IS DONE ON ESTABILISHED CASES.
1. excision of all dead and necrotic tissues
2. iv antibiotics and analgesics to be continued
as in prophylaxis
3. blood transfusions
4. polyvalent antigas- gangrene serum
5. hyperbaric o2 chamber
6. do not hesitate to amputate (if to save
life):guillotine type
7. correct hypotension
49

50. TETANUS (LOCK JAW)
• is a serious infection with very high mortality
cause :clostridium tetani (anaerobic
sporforming-terminal spore with drum stick
like appearance)
predisposing factors :
– lack of immunization
– presence of foreign body in the wound
– Injury by rusted or dirty objects
– presence of necrotic tissues
– improper sterilization
– anaerobic conditions etc.
50

51. POSSIBLE ROUTS OF INFECTION
OF TETANUS
1. umbilical cord (neonate by applying cow
dung)
2. wounds
3. minor injuries with (rusted nails, piercing ear
lobe,tattooing,injection etc.)
4. endogenous infection in:
• septic abortion
• puerperal sepsis
• GI. Operations
• 5. acquired in the operation theatre
(improper sterilization of instruments-
with 100% mortality)
51

52. PATHOPHYSIOLOGY OF TETANUS
The tetanus bacteria remains confined
to the area of inoculation and exert a
virulent effect by the production of 2
powerful exotoxins :
1. tetanospasmin (neurotoxin)
2. tetanolysin (haemolysin)
52

53. PATHOPHYS.OF TETANUS CONT.
TETANOSPASMIN : reaches the CNS. along the axons of
motor nerve trunks.
• there, it gets fixed to the motor cells of anterior horn
cells(motor end plates), inhibits the release of
cholinesterase and cause the accumulation of the
acetylcholine at the motor end plate and produces tonic
rigidity of the muscles.
• it also produces reflex contraction of muscles to minor
stimuli acting at the spinal cord level.
• the toxin fixed to the nervous tissue can not be
neutralized , but the circulating can be neutralized.
TETANOLYSIN (HAEMOLYSIN) : produces haemolysis.
53

54. INCUBATION PERIOD OF TETANUS
& PROGNOSIS
INCUBATION PERIOD : few days to months and
years
PROGNOSIS : depends on the period of onset,
(interval between the 1st. symptoms and the
appearance of reflex spasm :
1. short (<48hrs.) : poor
2. long(>48hrs.) :better
54

55. CLINICAL FEATURES OF TETANUS
• trismus(lock jaw) due to masseter muscle
contraction
• dyphagia due to pharyngeal muscle spasm
• neck rigidity
• rigidity of back muscles
• risus sardonicus due to contraction of facial and
jaw muscles
• mild hyperthermia
• tachycardia
55

56. DIFFERENTIAL DIAGNOSIS OF
TETANUS
• alveolar abscess
• temporomandibular joint disorder
• tonsillitis
• meningitis
• orthopedic disorders
• anxiety neurosis
• epilepsy
• sympathetic hyperactivity
56

57. RX. OF TETANUS
IS BASED ON :
1. prophylactic Rx
2. curative Rx.
57

58. PROPHYLACTIC RX. OF TETANUS
• immunization with tetanus toxoids and booster
doses q/ 5yrs.
• tetanus antitoxin(250units of human anti-tetanus
globulin) in :
– penetrating wounds of face & head
– wounds with necrotic tissues
– wounds of RTA.
– war wounds
• surgical toileting of wounds
• high doses of penicillin
58

59. CURATIVE RX. OF TETANUS
1. general Rx.
2. specific Rx.
59

60. GENERAL RX. OF TETANUS
1. admission and isolation in a quite and dark room
2. wound care:
-pus drainage
-removal of foreign body.
-proper dressings
3. tetanus toxoid IM after skin test
4. anti-tetanus serum after skin test
5. human antitetanus globulin (doesn’t need skin
test)
6. cryst. penicillin q/6hrs.iv for 7-10 days
60

61. SPECIFIC RX. OF TETANUS
Is given according to the seriousness of the
case :
• mild case
• seriously ill
• dangerously ill
61

62. SPECIFIC RX FOR MILDLY ILL
TETANUS PT.
THERE IS ONLY TONIC RIGIDITY
NO SPASM NIETHER DYSPHAGIA. :
• heavy sedation in isolated and dark room
• antibiotics (penicillin)
• analgesics/antipyretics
• wound care
62

63. SPECIFIC RX. FOR SERIOUSLY ILL
TETANUS PT.
Is carried on a pt. with dysphagia and reflex
spasm :
• heavy sedation in isolated and dark room
• antibiotics
• analgesics/antipyretics
• feeding through NG. tube
• traqueostomy (if breathing difficulty)
63

64. SPECIFIC RX. FOR
DANGEROUSLY ILL TETANUS PT.
This is a tetanus pt. with major cyanotic convulsion,
dysphagia and reflex spasm :
the Rx. is based on :
 antibiotics
 analgesics/antipyretics
 wound care
 feeding through NG. tub
 intubation and mechanical vent. with muscle
relaxants
 decompress u. bladder by catheter
 cleansing enemas
 frequent positional changes
64

65. CHRONIC SURGICAL INFECTIONS
Are due to chronic diseases such
as Tb, actinomycosis, leprosy and
Madura foot.
They form chronic abscess
(infections) which can be treated
and solved by corresponding
medications.
65

66. POSTOPERATIVE
INFECTIONS
INCLUDE :
1. surgical wound infection
2. intraperitoneal abscess collections
3. pancreatitis (unknown cause)
4. parotitis (in elderly & debilitated pts.by staphylococcus
aureus
5. hepatic infections
6. UTI
7. septic thrombophilebitis
8. pneumonia/bronchopneumonia
9. pseudomembraneous enterocolitis
66

67. SURGICAL WOUND INFECTIONS
CAUSES :
1) type of operation :
 clean
 clean contaminated
 contaminated
 dirty (septic)
2) poor surgical technique
3) inappropriate handling of tissues
4) inadequate hemostasis
5) bad tissue approximation
6) presence of dead space
7) poor aseptic and antiseptic technique
8) abuse of electrocautery
9) abuse of ligatures
10) poor blood supply to the wound
11) presence of hematoma, etc. 67

68. RX. OF SURGICAL WOUND
INFECTION
 open the wound widely (the
superficial layers)
culture and sensitivity of the
pus
subsequent wound care
68

69. INTRAPERITONEAL ABSCESS
COLLECTIONS
• TYPES :
1. Sub diaphragmatic
2. sub hepatic
3. Douglas / rectovesical pouch
abscess
4. interloops
69

70. CAUSES OF INTRAPERITONEAL
ABSCESS COLLECTIONS
1. septic operations
2. inadvertent hollow viscous perforation
during operations
3. intestinal suturing dehiscence
4. infected hematoma
70

71. RX. OF INTRAPERITONEAL
ABSCESS COLLECTIONS
 reoperation
culture & sensitivity of the pus
sucking out the pus , lavage and drainage
 antibiotics
analgesics/antipyretics
71

72. POSTOP. PANCREATITIS
CAUSE : is unknown
RX. :
• NPO.
• NG. tube
• hydration
• analgesics/antipyretics
• antibiotics
• Anti-enzimes (trasilol)
• RBS frequently and regular insulin
accordingly.
• Dosification of ca. levels
72

73. PAROTITIS
CAUSE : staphylococcus aureus in elderly and
debilitated pts.
RX. :
• hydration
• antibiotics
• analgesics / antipyretics
• sucking on hard candies to stimulate parotid’s
secretion
73

74. HEPATIC INFECTIONS
INCLUDE :
1- liver abscess due to septic thrombophilebitis of the
portal vein
2- ascending cholangitis
RX. :
 antibiotics
 analgesic/antipyretics
 drainage, if no response to conservative Rx.
3- serum hepatitis :due to admnis. of serum/plasma
RX.
maximize screening.
74

75. URINARY TRACT
INFECTION(UTI.)
CAUSE :
catheterization/instrumentation due to postop
urinary retention
RX.
• culture & sensitivity of the urine
• high fluid intake
• antibiotics
• analgesics/antipyretics
• encourage ambulation/activity
75

76. SEPTIC THROMBOPHLEBITIS
CAUSE :
• faulty technique of introduction of
catheters/canulas
• prolonged usage of plastic catheters/canulas
RX. :
• antibiotics
• analgesics/antipyretics
• warm moist compress
• early removal of canulas/catheters
76

77. PNEUMONIA/BRONCHOPNEUMONIA
CAUSES :
 atelectasia
 bronchoaspiration
 violence of aseptic and antiseptic measures
(anesthesia machines, endotraqueal tubes etc.)
 bed ridden pts.
RX.
 antibiotics
 analgesics/antipyretics
 resp. exercises
 ambulation/positional changes
77

78. PSEUDOMEMBRANOUS
ENTEROCOLITIS
CAUSE :
• overgrowth of staphylococci due to irrational use
of wide spectrum antibiotics.
• intest. mucosa damage due to hypovolemic
shock
RX. :
• specific antibiotics
• correct fluid and electrolyte imbalances
78

79. Any question????
79

80. BIBLOIGRAPHY
• BAILEY & LOVE’S : SHORT PRACTICE
OF SURGERY, 22ND. EDITION, 1995. and
25th. Edition.
• MANIPAL : MANUAL OF SURGERY,1ST.
EDITION, 2000.
• TEXT BOOK OF SURGERY : DAVID C.
SABISTON, 1997. and 18th. Edition 2007
• Schwartz’s Principles of Surgery 8th
edition.
80

81. THE END
•THANK YOU !!!
81