SURGICAL AND SURGICAL AND NOSOCOMIAL INFECTIONNOSOCOMIAL INFECTION

Miradz Hudaya., dr

Diki Zulkarnain., dr

Billy Yacub Rafel Talakua., dr

HISTORICAL BACKGROUNDHISTORICAL BACKGROUND

Reducing the mortality associated with Reducing the mortality associated with surgery :surgery :

Preventing microbial penetrationPreventing microbial penetration

Reducing the microbial inoculumReducing the microbial inoculum

Treating established infectionTreating established infection

The Famous Names of Surgical The Famous Names of Surgical and Nosocomial Infectionand Nosocomial Infection

Ignaz Semmelweis 1846Ignaz Semmelweis 1846

Louis Pasteur 1849 “Germ Theory”Louis Pasteur 1849 “Germ Theory”

Joseph Lister 1859Joseph Lister 1859

Robert Koch 1867Robert Koch 1867

Charles Mc Burney 1889 “Source Charles Mc Burney 1889 “Source Control”Control”

Pathophysiology of infectionPathophysiology of infection

Three factor must be exist :Three factor must be exist :

1. An inoculum of pathogens1. An inoculum of pathogens• Sufficient numberSufficient number• VirulenceVirulence

2. A nutrient medium on which microbes can 2. A nutrient medium on which microbes can thrivethrive

3. Some alteration in host resistance must 3. Some alteration in host resistance must accuraccur

Host DefensesHost DefensesHost defenses Host defenses are important in are important in preventing mikrobial penetration into the preventing mikrobial penetration into the tissuetissue

lokal host defenseslokal host defenses tissue are protected tissue are protected from microbal invasion by a layer of from microbal invasion by a layer of epitheliumepithelium

systemic host defensessystemic host defenses consist of consist of phagositic cells, the imunphagositic cells, the imun system,complement system, coagulation system,complement system, coagulation and the kinin systemand the kinin system

Surgical Surgical InfectionInfectionInfections that require operative treatmentInfections that require operative treatment

Infections that result from operative Infections that result from operative treatmenttreatment

Infections that require operative Infections that require operative treatmenttreatment

1.1. Necrotizing soft tissue infectionNecrotizing soft tissue infection

2.2. Body cavity infections Body cavity infections

peritonitis, supurative pericarditis, peritonitis, supurative pericarditis, empyemaempyema

3.3. tissue, organ and joint infections tissue, organ and joint infections abscess, septic arthritisabscess, septic arthritis

4. Prosthetic device-associated infections4. Prosthetic device-associated infections

Infections that result from operative treatment

1.1. Wound infectionsWound infections

2.2. Postoperative abscessPostoperative abscess

3.3. Postoperative peritonitisPostoperative peritonitis

4.4. Postoperative body cavity infectionPostoperative body cavity infection

5.5. Prosthetic device related infectionsProsthetic device related infections

The development of surgical infection The development of surgical infection depends on:depends on:

1.1. Microbial pathogenicity and numberMicrobial pathogenicity and number

2.2. Host defencesHost defences

3.3. the local environtmentthe local environtment

4.4. Surgical techniqueSurgical technique

Microbial pathogenicityMicrobial pathogenicity

some mikrobes have virtually no ability some mikrobes have virtually no ability to cause infection in normal host can to cause infection in normal host can cause lethal infection in an individual with cause lethal infection in an individual with compromised host defensecompromised host defense

Host defenses Host defenses are important in are important in preventing mikrobial penetration into the preventing mikrobial penetration into the tissuetissue

lokal host defenseslokal host defenses

tissue are protected from microbal tissue are protected from microbal invasion by a layer of epitheliuminvasion by a layer of epithelium

systemic host defensessystemic host defenses

consist of phagositic cells, the imun consist of phagositic cells, the imun system,complement system, coagulation system,complement system, coagulation and the kinin systemand the kinin system

Local environmental factors Local environmental factors

may permit an infection to occur in a may permit an infection to occur in a person with minimal microbial person with minimal microbial contamination & with otherwise adequate contamination & with otherwise adequate host defensehost defense

A suture can reduce the number os A suture can reduce the number os S.aureusS.aureus

Fluid collection & edema Fluid collection & edema infection infection , , cause inhibit fagositosiscause inhibit fagositosis

Surgical techniqueSurgical technique

surgeon can reduce likelihood surgeon can reduce likelihood infection:infection:

handling tissue gentlyhandling tissue gently

removing devitalized tissue, blood,etcremoving devitalized tissue, blood,etc

using drain appropriatelyusing drain appropriately

Type of Surgical InfectionsType of Surgical Infections

1.1. Soft tissue infections Soft tissue infections Cellulitis and LymphangitisCellulitis and Lymphangitis

soft tissue abscesssoft tissue abscess

necroting soft tissue infectionnecroting soft tissue infection

TetanusTetanus

2.2. Body cavity infectionBody cavity infection

Peritonitis and intrabdominalPeritonitis and intrabdominal

EmpyemaEmpyema

Cellulitis & LymphangitisCellulitis & Lymphangitis

spreading infection of the skin and spreading infection of the skin and subcutaneus tissuesubcutaneus tissue

caused by Strep. Pyogenes, S.aureus,caused by Strep. Pyogenes, S.aureus,

Strep.pneumonia, H.influenzaeStrep.pneumonia, H.influenzae

and aerobic and anaerobic gram and aerobic and anaerobic gram negative bacterianegative bacteria

Soft tissue abscessSoft tissue abscess

-> mostly found on the back-> mostly found on the back

-> most common cause by Stap.aureus-> most common cause by Stap.aureus

Necrotizing soft tissue infectionsNecrotizing soft tissue infections

most caused by mixed aerobic and an most caused by mixed aerobic and an

aerobic gram negative and gram positiveaerobic gram negative and gram positive

bacteria.bacteria.

Clostridium spesies Clostridium spesies

Peritonitis and intraabdominal abscessPeritonitis and intraabdominal abscessprimary peritonitis caused by a singleprimary peritonitis caused by a singleorganismorganismmost common in young children and adults most common in young children and adults with ascites or CRFwith ascites or CRFSecondary bacterial peritonitisSecondary bacterial peritonitisussualy the result of a defect in GITussualy the result of a defect in GITTertiary peritonitisTertiary peritonitisperitonitis like synd. peritonitis like synd. result of disturbance result of disturbance host immune responsehost immune responsecaused by fungi or low grade pathogenic caused by fungi or low grade pathogenic bacteriabacteria

EmpyemaEmpyema

ussualy due to pneumoniaussualy due to pneumonia

treatment -> evacuationtreatment -> evacuation

Treatment of Surgical InfectionTreatment of Surgical Infection

ResuscitationResuscitation

Appropiate use of antimicrobial agentsAppropiate use of antimicrobial agents

Source controlSource control

NOSOCOMIAL INFECTIONNOSOCOMIAL INFECTION

DefinitionDefinition• Tranmission of pathogen organism to the Tranmission of pathogen organism to the

patient no had infection before.patient no had infection before.

Clasification of nosokomial infectionClasification of nosokomial infection• Community based acquire infectionCommunity based acquire infection• Hospital based acquire infectionHospital based acquire infection• Operating based room acquire infectionOperating based room acquire infection

PATHOPHYSIOLOGYPATHOPHYSIOLOGYThe two key features contributing to the The two key features contributing to the development of N.Idevelopment of N.I

1.1. Reduction in the patient’s normal immune or Reduction in the patient’s normal immune or defense systemsdefense systems

2.2. Colonizations by pathogenic or potentially Colonizations by pathogenic or potentially pathogenspathogens

Specific Nosocomial InfectionSpecific Nosocomial Infection

Urinary tract infectionsUrinary tract infectionsLower Respiratory tract Infection Lower Respiratory tract Infection (nosocomial pneumonia)(nosocomial pneumonia)Bloodstream infection (venous line)Bloodstream infection (venous line)Surgical site infectionSurgical site infectionothers others

Wound classificationWound classification

Wound ClassWound Class ExpectedExpected infection Ratesinfection Rates

CLEANCLEAN 1,0 - 5,4 %1,0 - 5,4 %

CLEAN CONTAMINATEDCLEAN CONTAMINATED 2,1 - 9,5 %2,1 - 9,5 %

CONTAMINATEDCONTAMINATED 3,4 - 13,2 %3,4 - 13,2 %

DIRTYDIRTY 3,1 - 12,8 %3,1 - 12,8 %

Superficial surgical Wound Superficial surgical Wound InfectionInfection

Superficial surgical Wound Infection Superficial surgical Wound Infection →→ An incisional An incisional wound infection occurs wound infection occurs →→ within 30 days after within 30 days after operation operation →→ involves skin or subcutaneous tissue involves skin or subcutaneous tissue above the fascial layer & any of the followingabove the fascial layer & any of the following

1.1. There is purulent drainage from the incision or a drain There is purulent drainage from the incision or a drain located above the fascial layer.located above the fascial layer.

2.2. An organism is isolated from culture of fluid that has An organism is isolated from culture of fluid that has been aseptically obtained from a wound that was been aseptically obtained from a wound that was closed primarily.closed primarily.

3.3. The wound is opened deliberately by the surgeon, The wound is opened deliberately by the surgeon, unless the wound is culture-negative.unless the wound is culture-negative.

Deep surgical wound infection Deep surgical wound infection Deep surgical wound infection occurs Deep surgical wound infection occurs →→ within 30 within 30 days after operation, involves tissues or spaces at or days after operation, involves tissues or spaces at or beneath the fascial layer and any of the followingbeneath the fascial layer and any of the following

1.1. The wound spontaneously dehisces or is deliberately The wound spontaneously dehisces or is deliberately opened by the surgeon when the patient has a fever opened by the surgeon when the patient has a fever (>38°C) and/or there is localized pain or tenderness, (>38°C) and/or there is localized pain or tenderness, unless the wound is culture-negative.unless the wound is culture-negative.

2.2. An abscess or other evidence of infection directly An abscess or other evidence of infection directly under the incision is seen on direct examination, under the incision is seen on direct examination, during operation, or by histopathologic examination.during operation, or by histopathologic examination.

3.3. The surgeon diagnoses infection.The surgeon diagnoses infection.

How to prevent InfectionHow to prevent Infection

Human characterHuman character

RegulationsRegulations

Antibiotic prophylaxisAntibiotic prophylaxis

Good Surveillance systemGood Surveillance system

Source control1. Remove/treat infection2. Remove/treat inflammation3. Remove dead tissue4. Stabilize injured tissue5. Restore microcirculation

Source control1. Remove/treat infection2. Remove/treat inflammation3. Remove dead tissue4. Stabilize injured tissue5. Restore microcirculation

Resuscitation1. Minimize flow-dependent oxygen consumption2. Minimize flow-dependent lactate clearance

Resuscitation1. Minimize flow-dependent oxygen consumption2. Minimize flow-dependent lactate clearanceNutrition/metabolic

support1. Achieve nitrogen balance2. Avoid calorie overload3. Avoid long-chain fat overload4. Appropriate vitamins, minerals, trace elements

Nutrition/metabolic support1. Achieve nitrogen balance2. Avoid calorie overload3. Avoid long-chain fat overload4. Appropriate vitamins, minerals, trace elements

General approach to therapy: General approach to therapy: prevention as its primary goalprevention as its primary goal

THANK YOUTHANK YOU