Most dreaded problems surgeons presented with
o Requires surgical treatmet
o Something that is caused by surgical problem initially or post-op; it
appears from some reason or another
Classification
Clean Wound
o Don't expect any problems with pt post op; do not have any infection;
o Non traumatic; no break in the technique - sterile technique where
everything has to be clean has not broken; nothing fell on the floor;
anyone who touches instrument also aseptic
 No break in Git tract
o Don't operate on urinary, GIT, respi tract
 Thyroid operation - above traches
 Operate on it; don't have to enter the trachea; nothing
else disturbed but the thyroid
 So don't expect infecion in theses pts post operatively
Clean Contaminates
o Git, respi, uro tract has been entered
o Low post op infections
 1-1.5 % (initiially)
 3-5%
o
o
o
Minimal spillage
Gallbladder
 Elective will not have bile infection
 But we give antibiotics pre op
 Might expect wound infection ---quite rare (3-5%)
Early appendectomy
 Congested appendix --still clean contaminated
Contaminated Wound > 5-10%
o Major break in technique
o Break in presence of infected fluids
o Acute consistitis
 Bile is infected
Dirty Wound
o With dead, devitalized tissue
o Fecal material may have spilled
o Perforated viscus - close it up to fascia, leave subcutaneous and skin
layer open (delayed closure)
o 10-15% infection
o Ruptured colonic
o Abscisses
We categorize our patients because it's for us to know whether to give antibiotics or
not pre-op
o Elective surgery  Clean - don't expect infection post op
 So don't give antibiotics pre and post operatively
Example - thyroid, breast surgery, excision biopsies in
skin; all are clean from start; no infections; inspect to
use sterile instruments
Clean Contaminated and Contaminated
 Already have an infection pre-op
 Clean - Give antibiotic (prophylactic) - don't want
infection in that organ to spread to the wound (incision
site); so give pre-op antibioticd (double the usual dose);
give about an hour prior to surgery so tissues have
adequate dose by surgery
 Congested appendicitis, acute colonocitis
 Clean Contaminated - 750 mg (usual dose)
 For pre op -- double dose -- 1.5 gms
 Post op --give 750 mg for 3 more doses or for
one more day
 Removal of organ during surgery plus
antibiotic -- pt safe from infection
 Contaminated
 Give a pre-op antibiotic
 It's good because sometimes when have
contaminated, antibiotic may transform
contaminated organ into clean-contaminated
organ; bit safer
 Also give antibiotics for 24 hours
Dirty wounds
 Already dirty
 Preop antibiotics - same dose/time
 Give it for 7 days
 Not prophylactic anymore
 But therapeutic antibiotics - gross contamination,
spillage, contamination; have to treat the infection

o
o
Wound Prevention aside from Antibiotic administration
o Avoidance of bacterial contamination
 If instruments, room, gloves is contaminated with bacteria, no
matter how clean surgery is, you'll have post op surgery
infection
o Avoid exogenous/endo contamination
 From the pt himself and from outside (nurses, dr) = they
should all be clean; don't let anyone with pneumonia in the
operation room
o Use of UV light and laminar flow
 Uv light - used for water - bacteria will go to the pipes
 Grossly contaminated surgery - don't just clean OR with
acid; use UV light to kill anymore remaining bacteria
 Laminar flow -- one unidirectional air flow going out; don't get
airconditioner that gets air outside going in - Inundation of traffic from in to out of OR
 When surgery done, expect 20 people inside; surgeons;
10 clerks, 10 nursing students;
o Limitation of talking and activity
 Wear masks to protect the pt also
o
o
Pre Op preparation
 Pre op shower; if stab wound, maybe not
 If elective surgery, ask pt to take a shower the night before
Cutaneous infection
 Should be controlled
 Cellulitis
o
Hair removal
 Injury of shaving may promote bacterial growth
 Initially done night before surgical procedure; it can promote
cuts in the skin; pt brought in OR - the next morning will bring
all the bacteria he got in the ward
 Now - 1hr prior to surgery; shaving done in OR
 Use a depulator - pulls out the hair
o
Skin prep
 Scrub area for 5-7 minutes with solution
 Paint with povidone-iodine (soap and disinfectant are different)
 Works within 45 seconds upon applying
 In ER, can be done in 1 minute
 Use anti-microbial incision tape
 Exclusive type of tape - place it all around areas you
plan to operate on
 Drape with a hole in the center; borders have a
tape which sticks to the skin; barrier from the
outside skin
Wear clean scrub suits
 Cap and mask
 Gown, cap, mask and goggles used now
 Not just for pt to protect dr's from pts but to protect
doctors from patients with all airbourne diseases
 Bare hand operations
 Pt will not get infections
 Without cap/mask, without drape, gown
Alcohol solution --rinsing not required anymore
 30 seconds
 Scrubbing only done in 5 minutes
o
o
o
o
o
Make sure drapes are clean - don't let it drag on sides of bed or other
parts of OR
Change punctured/torn gloves
 20% of all surgeons after surgery had a punctured glove
 Didn't know about it - just continued; nothing happened
to patient, but the doctor was contaminated
Avoid contamination of surgical wound at time of transection
 Colon - how do you protect sides of the wound
 Use operating sponges that you put around border of
incision to protect the sides of wound - to prevent bile
spillage; if it spills, sides will be protected by the
sponges
Diagnosis of Wound Infection
o
o
o
Redness, swelling, heat, pain, loss of function, fever and chills
Appendectomy
 On the 3rd post op day, send pt home
 Ask them to come back after 7 days from time of
surgery
 Most of the time, surgery successful
 Pt comes back walking straight
 If he's bent over holding side, inspect wound has
become infected; very painful -- already puss
underneath the skin --- so you have abscess (in the
teeth - have it pulled, in the arm, anywhere in the body)
---very painful
 Only way to relieve pain is to open up the wound and let
the abscess (puss) out
Causes of wound infection

Should be enough of bacteria there; 1 or 2 won't cause
contamination
 Won't grow because your inherent antibodies will be
able to destroy the bacteria
 If 100 thousand there, host defenses (neutrophils,
macrophages) are overwhelmed
o
Position and growth of
 No bacteria, no infection
o
Type and number
 If you have staph epidermidis in the wound, most likely no
infection
 If you have staph aureus, strep, then you Will get infection
 Number
 Have hemolytic staph/strep
 If 1000 present, will not get infection
 If 100,000, you will get infection
o
Surface Component
 Factors in the bacteria itself that prevent them from being
destroyed by immune system
 Endotoxin
 In gram negative bac
 eColi - found in all organs in the body (GI tract);
if overgrowth of eColi, then infection
 Lipopolysaccharides - makes the bacteria
slippery so that macrophages cannot
engulf them; difficult to destroy
 Exotoxin
 Gram positive
 Bact contamination > 100,000 cause infection
Local Wound factors
 Inhibition of local defense for clearing bacteria out
 Blood supplies - if it's destroyed in that area
 Burns - good chance that area will be
contaminated/infected later on
o

Bette blood supply, better defense
Of skin,
What layer has the poorest blood supply?
o Subcutaneous fat -- gets most infected
 Bears the brunt of any infection
o Skin - good blood supply
o Muscles - excellent blood
 Rare infections
o Peritoneum - good blood supply
Inhibition of phagocytic cells to directly contact and kill the bacteria
o Diabetes (uncontrolled)
 Ability of own macrophages to attach themselves to bacteria is
diminished;
 Macro unable to grasp, engulf and destroy them
 Phagocytosis is inhibited
 Once you control diabetes, infection rate is controlled as normal
Patient Factors
Age, reduction in blood flow, vascular reactivity, malignancy or trauma
o Age (very young or old)
 Have very incomplete/poor immune system
o Reactivity
 Ability to bring in macrophages
o Malignancy or trauma
 Increase wound infection
o Anemia
 Will not increase the infection rate
 Hemoglobin rate of 7 or 8
 Not known why
 Doesn't interfere with the immune system
o Malnutrition
Surgical techniques
o Don't avulse tissues
o All dead tissues and foreign bodies should be removed
 Sources for infection
 Debridement - process name
o Use of monofilament sutures for infected wounds
 Monofilament suture - made of one strand
 braded suture - 5 or 6 intertwined sutures; bacteria hiding
within braded spaces that were not accessible to the antibiotics;
 Monofilament advocated - the bacteria was hiding in the
interplane sutures
 One suture - can't hide
 Proline, thymine
o Avoid hematomas, seromas and dead space
 High in protein
 Agar plates - where bacteria grow and thrive in

Dead space - you took out a lump beneath skin; skin is loose; if
you close skin, there's a space where lump used to be; space
where seroma will grow -- it will let the bacteria proliferate
Systemic Factors
o Host resistance
o Malnutrition
o Avoid usage of so many drugs; post-op, avoid the drugs
o Advocate the use of 1 antibiotic only for any infection; sometimes you
hear pt give 3-4 antibiotics for pneumonia; 1 advocated only
 How will you know which antibiotic to use
 Get culture and sensitivity of that wound
 Waith 3-5 days
 In the meantime, use antibiotic
 Ecoli --give 2nd generation
 Then use particular antibiotic that has been specified by
the test
 Sometimes amoxycillin is the simple drug that
you only have to use
o
Systemic Prophylactic Chemo and Antibiotics
 All antibiotics have a side effect; PINS -phil index of …
 List of all drugs available in country with dosage, prep,
tablet, id
 Side effects at the bottom (contraindicator)
 Have to weigh benefit of that drug against adverse
effects
 Drug may cause an abortion
 Shotgun therapy - pt comes in, fever == don't know exact
cause; you give 3 drugs
 One for gram positive, negative and ..
 Shotgun not used -- will kill all bacteria; will also kill
beneficial bacteria especially in the colon causing a
superinfection
 Colitis - indiscrimate use of drugs cause
infection; all beneficial bac in colon destroyed
followed by powerful infection caused by
claustridium …
 If you use 2nd/3rd generation antibiotics, some
bacteria is already resistant to it, so you have to
give an entirely new antibiotic for it to work
 Good time to do blood workup
 Not done for 2-3 days
 When you get culture sensitivities back, then you get antibiotics
 By 3-4 day, you should have diagnose already
 Secondary or superimposed infection
 Hypersensitivity reaction
 If have 5 drugs in that pt and he develops reaction, you
don't know which of the 5 drugs caused it
 Mask signs and symptoms of infection
 Not only infection causes problem
 Obstruction
 Acute appendicitis

o
o
15 yr old pt -- right quadrant pain
 Vague pain - came in 6 hours from
onset of pain (epigastric)
 Ultrasound will not help diagnosis
 CBC normal; neutrophils rising
 No fever
 Slight anorexia, no vomiting -everything still vague
 Don't operate yet in pt. Usually tell
parents that we will observe pt overnight.
Next morning 12 hours later - during
observation, don’t' give analgesics or pain
will disappear
 Don't give antibiotics - may mask
signs and symptoms of infection
 Obstruction is still there - appendix still obstruction;
antibiotics hasn't stopped it; it
superficially took out only
 If next day, pain progressed ----do
surgery
 If it disappeared
 Observe longer
 Do CBC if it went down
Development of resistant stains
 Give antibio --destroyed 90% of bacteria
 10% survived and developed resistance; will now
proliferate and cause infection
 Get another antibiotic now; 90% destroyed other 10
resistant -- proliferate again ----continous cycle, never
ending
Principles of Antibiotic therapy
 General principle
 Achieve level of antibiotics at site of infection
 MIC
 Minimum inhibitory compensation
 Need to have enough amt to kill bacteria in that
area
 Can't happen all the time
 Burn - infected skin; give antibiotics;
antibiotics won't reach burned wound
because blood supply to the wound is
already destroyed
 If mild infection (sore throat)
 If signs of sepsis (leukocytosis greater than
12,000, temp > 36, heart rate > 90, respi rate >
20)
 Only need 2 of 4 to label sepsis
 Give IV antibiotics
 When do you stop giving IV antibiotics and shift to oral if
obvious improvement is seen
 If pt had fever and it settled, shift to oral
If pt has good bowel movement already, good sign pt is
doing well
 If pt hungry and passed gas, great sign pt is doing well
after surgery
 Can start oral
If no improvement in 2-3 days
 Procedure may not be adequate
 Live abscess - may not have adequately drained
the liver out
 Complications
 Superinfections
 Drug of choice may be correct but insufficently
administered
 Happens a lot; scared to push drug to the limit
esp in renal failure - which causes side effects or
a different drug maybe needed
Continue antibiotics orally
 No hard and fast true with 7 days
 No more "take for 7 days"
 Lots of diseases are now treated by 1-3 day
regimen
 Pneumonia -- 3 day treatment only
 Drug only 300 pesos
Surgeons
 Before you send pt home, opt for oral intake already for
5 days
 Imporved mental status
 Return of bowel function
 Spontaneous diuresis
 Superinfection
 New infection that develops during antibiotic
treatment for original infection
 Psuedomembranous colitis
 Membrane that covers colon that produces
severe diarrhea that causes dehydration
 Can kill pt fast due to dehydration
 2-10% antibiotic treated pt develops superinfection
 Limit the dose and duration of antibiotic
treatment
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Antibiotics
 Should be active against infecting organism
 Adequate contact btw the drug and offending microbe
 Absence of toxic side effects
 If you have immunocompromised and he depends on
antibiotics to control infection, most likely he will die
 Can't depend on antibiotics alone;pt should have
good immune system to augment antibacterial
properties of the drug