Surgical Infections
Key Points
Definition
Classifications
Etiology
Clinical Manifestation
Management
Specific Surgical Infections
Characteristics of Hand Infections
Definition
Infections be treated by surgical intervention
Infections following surgical procedure
(wound or distant site)
Classifications
Non-specific infection
Furuncle & Carbuncle
Cellulitis & Erysipelas
Hand infection
Acute appendicitis
Acute peritonitis
Breast abscess
Classifications
Acute infection (<3w)
Most non-specific infection
Tetanus
Gas gangrene
Chronic infection (>2M)
Tuberculosis
Sub-acute infection (3w-2M)
Urine tract infection
Fungal infection
Classifications
Local phase
Skin infection
Soft-tissue infection
Hand infection
Abscess
Systemic phase
Bacteremia
Sepsis
Etiology：Pathogenic Microorgansim
Bacteria
Virus
Fungi
Endotoxin
Ectotoxin
Enzyme
Etiology：Local Factors
Trauma
Ischemia and Hypoxia
Obstruction
Presence of Foreign Bodies and Necrotic Tissues
Ionizing Radiation
Edema
Etiology：Systemic Factors
Severe Trauma
DM
Cancer, Chemotherapy
Leukemia
AIDS
Immunodeficiency
Malnutrition
Results：Non-specific Infections
Cure
Dissemination
Abscess formation
Bacteriamia & Sepsis
Chronic infection
& SIRS & MODS
Results：Specific Infections
Mixed
infection
Tuberculosis
Systemic
infection
gas gangrene
Opportunistic infection
Fungi
Tetanus,
Clinical Manifestation：
Localized surgical infection
Redness
Swelling
Pain
Heat
Loss of function
Clinical Manifestation：
Physical Exam：
Intravenous cannula---purulent drainage or thrombophlebitis
Rectal examination---pelvic abscess
Auscultation of chest---pneumonia
Physical Exam： Exudate
Accumulation of extracellular fluid
Color, odor, character
Be useful in categorizing the causative organism

Gram stain
an essential procedure for diagnosis and treatment

Physical Exam： Biopsy
Being necessary for diagnosis sometimes
Especially for granulomatous infection
Tuberculosis
blastomycosis


Culture：
Exudate
the most reliable diagnosis for treatment
Both aerobic and anaerobic culture
Blood
Diagnostic step for unknown source
Fail to capture causative organisms in bacteremia
Unnecessary to diagnose sepsis
Sputum
Urine


Principle of Antibiotics Management:
Bacteriostatic agents
Prevent
growth of bacteria
Bacteriocidal agents
Actually
kill bacteria
Effective agent against the infecting organism
Adequate contact between agent and organism
Absence of toxic side effect of the agent
Augmentation of host defenses to maximize antibacterial
effects
Culture
before antibiotic therapy
antibiotics on empiric basis before the laboratory reports
Culture and sensitivity test (Evidence basis)
a combination of antibiotics for probable polymicrobic infection
Administer
Colonization
The quantitative appearance of changes in the microflora that are induced by antibiotic
therapy
Superinfection
A new microbial disease introduced or potentiated by antibiotic therapy
Superinfection is frequently the result of colonization.

for potentially contaminated wounds
Only an adjunct and NOT a substitute to good surgical technique
Clean procedure
no
antibiotics are necessary
Clean contaminated procedure
Contact
of the interior of respiratory, urinary,GI tracts
Contaminated procedure
Complicated
by gross spillage of intestinal contents or wounds secondary to trauma
Dirty wounds
In
contact with intraabdominal or perirectal abscess
Malnourished
Obese
Elderly
Immunodeficient
Shock or MOF
Poor blood supply to the operative region
early and enough for adequate tissue and body fluid levels
Being necessary to maintain adequate tissue levels intra-operatively
length of operation and serum half-life of antibiotics
Surgical Infections
Etiology：Pathogenic Microorgansim
Staphylococci—G+
beta
hemolysins
Suppuration and Characteristic pus
thick,
yellow, without foul smelling
S. aureus – furuncle & carbuncle
S. epidermidis – after surgery with foreign material
High Risk Factors
Obesity
Diabetes
Poor hygiene condition
Intravenous drugs
Furuncle：
Infection involving an entire hair follicle and the underlying skin tissue
Face
Buttocks
Thighs
Groin
Breast
Axil area
<2cm
raised, tender, shiny, bright red
intense, throbbing pain
yellow or white creamy discharge
(matured)
A confluent infection
involving multiple contiguous follicles
limited to the subcutaneous tissue
thick overlying skin and dense subcutaneous fascia
Carbuncle：
Back of Neck or Torso
Pain, swelling, induration of the surrounding skin
Multiple small abscess with yellow thick pas
Fever, fatigued, leukocytosis, even sepsis
Leision
care
help to “mature”
Surgical incision drainage
Large & deep enough incision for carbuncle
Antibiotics
Penicillin
Erythromycin
Clindamycin

good hygiene condition
avoiding intravenous drug
loose clothing
Connective tissue
dermis and subcutaneous tissues
acute spreading
pain, erythema, edema, and warmth
trauma or surgery
causing a lesion in the skin
may have no discernible dermal injury
develops over a period of several days
The affected area
Warmth
Erythema
Edema
Tenderness
The proximal to the area
 Ascending lymphangitis
lymphadenopathy
Significant
erythema
eroded area near the center
Irregular margins but not raised
An ulcerated area in the center
Painful and warm to the touch
An
normal
group A streptococci & Staphylococcus aureus

Infants
group B streptococci

Immunocompromised
Pneumococcus gram-negative rods or fungi
Wounds
Aeromonas hydrophila, gram-negative rod

Bacteremia
Local abscess
Superinfection with gram-negative organisms
Lymphangitis
Thrombophlebitis
Facial cellulitis in children (meningitis in 8%)
Gas gangrene(amputation & mortality in 25%)
Escherichia coli in nephrotic syndrome
Cellulitis of the lower extremities in geriatric patients (thrombophlebitis)
Pseudomonads in immunocompromised children
Antibiotics:
penicillinase-resistant synthetic penicillin
first-generation cephalosporin
clindamycin
metronidazole
caused by group A beta-hemolytic streptococci
Involving dermis and lymphatics
more superficial subcutaneous infection than cellulitis
characterized by intense erythema, induration, and a sharply
demarcated border,
Abrupt onset of illness (Painful rash)
Initial fever and chills (1-2 days later)
Muscle and joint pain
Nausea
Headache
Systemic infectious manifestations
Skin discomfort
Fever
Dermatologic
signs
Painful, erythematous, and edematous rash
Sharply-raised border with abrupt demarcation from healthy adjacent skin
Lymphangitis
Erythema (irregular extensions)
Desquamation
Vesicles
Lymphadenopathy

Group A streptococci (the most)
Group G, C, B streptococci (less)
Staphylococci (rarely)
Antibiotics (as soon as possible)
Penicillin
Erythromycin
Cephalexin
Symptomatic treatment
Antipyretic
Analgesics
Hydration (oral intake if possible)
Cold compresses


Gangrene & Amputation
Bacteremia & Sepsis
Scarlet fever
Pneumonia
Abscess
Embolism
Meningitis
Death
The infection of lymph nodes (glands)
usually associated with the site of the underlying infection,
common result of a cellulitis or other bacteria infection
tumor, inflammation
swollen,
tender, hard nodes
or irregular to touch
or soft and "rubbery" (fluctuant) if an abscess has formed
the skin over a node may be reddened and hot
smooth
Infection
of lymph vessels/channels
results from cellulitis or abscess in the skin or soft tissues
A progressing infection raising spread of bacteria to the bloodstream
life-threatening infections
Be confused with a clot in a vein (thrombophlebitis)
Commonly
red streaks
from
infected area to the armpit or groin
throbbing pain
along
the affected area
lymph nodes
fever and chills
malaise,loss
of appetite, headache, muscle aches
Physical examination
Biopsy (LN)
Blood culture
Lymphadenitis and lymphangitis may spread within hours, spreading to the bloodstream may be
fatal.
Treatment should begin promptly
Specific antibiotics
Surgical drainage
Hot moist compresses
Hand Infection
Anatomy factors
Multiple compartments and planes in hand
Infections are dictated by fascial boundaries in hand
Paronychia
Felon
Tenosynovitis
Deep fascial space infections
The lateral nail fold
Starting as a cellulitis, progression to abscess formation
Eponychia (spreads to the proximal nail edge)
Recent trauma to lateral nail fold
Nail biting
Manicuring
Dishwashing
Finger sucking （children）
Edema, Erythema, Pain along lateral edge of nail fold
May have extension to proximal nail edge (eponychium)
Possible abscess formation
Staphylococcus & Streptococcus in most cases
Mycobacteria and fungi in chronic cases or immunocompromised patients
Anaerobes in the pediatric population due to finger sucking.
If
no frank abscess
frequent hot soaks & antibiotics
If pus is present
incision and drainage
If pus has tracked beneath the nail
remove an adjacent longitudinal section
If eponychia is resulted
remove the entire nail plate
Eponychia (Subungual abscess )
Osteomyelitis of the distal phalanx
Development of a felon
Chronic infection
Most resolve in 2-4 days
Chronic infections are likely fungal infections.
The infection of distal palmar phalanx
Compartmentalized infection
Increased pressure within the closed compartment
Impaired venous outflow
a local compartment syndrome and myonecrosis and
osteomyelitis
Staphylococcus & Streptococcus is the most common causative organism
Typically direct inoculation of bacteria by penetrating trauma
May be caused by hematogenous spread
Local spread from an untreated paronychia
Recent trauma to finger pad or paronychia
Typically Throbbing Pain
Swelling, Pressure, Erythema
Painful, Tense, Erythematous finger pad
Pointing of abscess possibly present
Signs typically limited to area distal to the distal interphalangeal joint
Evidence of penetrating trauma
Frank abscess & tense finger pad is the indication
A longitudinal incision over the area of greatest fluctuance
To avoid penetration of the tendon sheath, the incision
should not extend to the distal
interphalangeal crease
Using a hemostat, bluntly dissect the wound to promote drainage
Irrigating the cavity copiously and loosely pack with a gauze wick.
scarring
sensory loss
unnecessary pain
instability of the finger pad
spread of infection into the adjacent tendon sheath.
Reevaluate
the wound 48 hours after initial incision
continued drainage is present, loosely repack the wound
no further drainage is present, repacking is unnecessary
Continue antibiotics for 5-7 days
The prognosis is good, with healing in 1-2 weeks
If
If
Osteomyelitis
Necrosis
Sinus tract formation
Septic joint
Tenosynovitis
The
tenosynovial coverings of the second, third, and fourth digits do not communicate with
either the radial or ulnar bursae in most individuals
Infection within a tendon sheath usually is the result of direct inoculation of bacteria from
penetrating trauma.
Recent penetrating trauma to hand
Gonococcal infection, particularly disseminated infection
Pain, especially with passive extension of finger
Edema of entire finger
Variable history of fever
Tenderness along the course of the flexor
Symmetric edema of involved finger
tendon
Pain on passive extension (the most important
Flexed resting posture of finger
sign)
All 4 signs possibly not present early in the course of infection
May have associated lymphangitis, lymphadenopathy, and fever
Tendon destruction
Functional disability
Extension of infection to deep fascial space
Deep fascial space infections
midpalmar space
thenar space
dorsal subaponeurotic space
subfascial web space
Recent penetrating trauma to hand or untreated tenosynovitis
Palmar blister (may result in subfascial web space abscess)
Pain and edema of hand
Pain with movement of fingers
Variable history of fever
Pain, swelling, loss of palmar concavity
Pain with movement of the third and fourth digits
Dorsal swelling secondary to the tracking of infection dorsally along the lymphatics
Marked swelling of the thumb-index web space
Flexed and abducted resting posture of the thumb
Pain with passive adduction
Functional disability
Tendon destruction
Sepsis
Hand loss
pain relief
antibiotic therapy
elevating and immobilizing the hand
consulting an experienced hand surgeon
incision and drainage
Depending on
the extention of tissue destruction
bony involvement
preexisting vascular insufficiency
systemic complications (bacteremia, sepsis)
Systemic Infections
Resulted from exotoxin produced by C.tetani
a severe disease primarily of older adults who are unvaccinated or inadequately vaccinated
Characterized by hypertonia, painful muscular contractions, muscle spasms
Clostridium tetani
An obligate anaerobic gram-positive bacillus
Formation of spores which are resistant to heat, desiccation, and disinfectants
Being ubiquitous in soil, house dust, animal intestines, and human feces
Animal bites
Burns
Chronic otitis
Crush injuries
Dental procedures
Elective surgical abrtion
Frostbite wounds
Human bites
Puncture wounds
Surgery
Median Incubation period = 7 days
73% = 4-14 days
15% = < 4 days
12% = >14days
clinical manifestations occurring within 1 week of an injury have more severe clinical courses
Mild penetrating wound even be healed before toxin development
Arrhythmias
Coma
Difficulty breathing
Difficulty swallowing
High blood pressure
Irritability
Neck pain & stiffness
Restlessness
Seizures
Trismus (lockjaw)—75%
Pain & Stiffness (neck, back, abdomen)
Dysphagia
Restlessness
Reflex spasms.
“Risus sardonicus” expression
Wound Management
TAT
Tetanus vaccine (DPT)
Tetanus immune globulin (for high-risk wounds or person who has never been immunized
injections)
to remove necrotic tissue and foreign bodies
to create an aerobic environment
Anticonvulsants
Valium
Luminal
Skeletal muscle relaxants
Baclofen
Dantrolene
Antitoxins
Tetanus immune globulins


Overall
mortality is approximately 45%
In the United States
mortality rate is 6% (previously tetanus toxoid)
mortality rate is 15% (unvaccinated individuals)
Most people recover from tetanus completely
Recovery from 2 to 4 months
Some individuals have low muscle tone after recovery.