Wound and surgical site infection

Dr Rania Talaat Abdel Haleem

 Learning objectives
• Explain the terminology related to wound infection.
• Discuss the etiology, pathogenesis ,epidemiology,
treatment and prevention
• Discuss virulence mechanisms and correlate virulence
mechanisms with specific pathogens
• Describe the laboratory diagnosis for bacteria
• Explain the relevance of bacterial resistance to the
treatment of wound infections.
• Discuss different methods for preventing wound
infection.
• The most common causative organisms
associated with wound infections include
Staphylococcus aureus/MRSA, Streptococcus
pyogenes and Pseudomonas aeruginosa.
Anaerobic bacteria such as Bacteroides and
Clostridium species may cause deeper wound
infections.
 Staphylococci
• Staphylococci are Gram-positive spherical bacteria that
occur in grape like-clusters and are catalase positive.
• S. aureus and S. epidermidis are the major components
of the normal flora of skin ,nose and mucous
membranes.
• Staphylococcus aureus :It causes a wide range of
suppurative infections (pus-forming) and toxic shock
syndrome .They are Gram-positive spherical cocci,
arranged in clusters (grape like) non-motile, non-spore
forming, facultative anaerobes .
 Virulence factors of S. aureus
• Coagulase enzyme
• Surface proteins that promote adherence to
host cell
• Production of extracellular enzymes and
toxins
• Inhibition of phagocytic engulfment
• Exotoxins that damage host tissues
• Resistance of S.aureus to antimicrobial drugs
 Virulence factors of S. aureus
• Coagulase is an extracellular enzyme which
enables the enzyme protease to convert
fibrinogen to fibrin, this results in clotting of
the blood. Coagulase is a marker for
identifying S. aureus. The bacteria protect
themselves from phagocytic and immune
defenses by causing localized lesion
Catalase test
 Virulence factors of S. aureus
• Production of extracellular enzymes and
toxins that promote bacterial spread in
tissues mainly ;
• leukocidin
• hyaluronidase
• proteases
• Lipase
• deoxyribonuclease (DNase).
 Virulence factors of S. aureus
• Inhibition of phagocytic engulfment by:
Protein A
catalase production
capsule production
 Virulence factors of S. aureus
• Exotoxins that damage host tissues: several
different types of protein toxins are responsible
for symptoms during infections
• Toxins with superantigen activity which stimulate
T cells non-specifically and release cytokines in
large amounts, causing the symptoms of toxic
shock
• Exfoliative toxins (ET): Responsible for scalding
skin syndrome. It cause separation within the
epidermis.
 Virulence factors of S. aureus
• Resistance of S.aureus to antimicrobial drugs:
– Hospital strains of S. aureus are resistant to a variety
of antibiotics except vancomycin.The term MRSA
refers to Methicillin (or multiple) resistant S.aureus.
S.aureus strains develop resistance to antibiotics
through different mechanisms either by mutation or
production of beta lactamase enzyme.
– Resistance to antiseptics and disinfectants which
help its spread in hospital environment.
– Beta-lactamase production by acquisition of
plasmids, transposons, or other types of DNA inserts.
This is present in 90% of S.aureus strains.
 Pathogenesis of S. aureus
• S. aureus causes a variety of suppurative infections and toxin
mediated diseases in humans.
• Pyogenic diseases include :
• Skin infections are very common e.g abscess ,severe necrotizing
skin and soft tissue infections are caused by MRSA strains.
• Hospital acquired (nosocomial) infections: S. aureus is one of the
major cause of surgical wounds .
• Septicemia:can originate from localized lesion especially wound
infection.
• Toxic shock syndrome and Scalded skin syndrome (SSS) :Blood
culture typically do not grow S.aureus
• Source of infection: either endogenous from skin and nasal normal
flora or exogenous by contact .
 Laboratory diagnosis of S. aureus
• Specimen : pus
• Direct microscopic examination:
Gram positive cocci in grape like clusters.
• Culture on blood agar:
Complete (beta) hemolysis.
• Catalase test is an important test to discriminate
between Staphylococci and Streptococcus species
• Typing of S .aureus is done for epidemiologic purposes,
in hospital wound infections outbreaks. This could be
achieved by phage typing, plasmid analysis, PCR.
 Prevention of S. aureus infection
• Cleanliness, and frequent hand washing, and
aseptic management of lesions
• Reduce persistent nasal colonization by
intranasal application of muporicin.
• Cefazolin is used perioperatively to prevent
staphylococcal surgical-wound infections.
 S. epidermidis
• Virulence factors of S. epidermidis:
• Adherence is an important step in the
initiation of infections by: polysaccharide
adhesion, and biofilm formation.
• The ability to form a biofilm on the surface of
a prosthetic device is a significant determinant
of virulence for these bacteria.
 Streptococci
• Streptococcus pyogenes is one of the most
important human pathogen in nose and
throat .Group A Streptococci typically have a
capsule composed of hyaluronic acid and
exhibit beta hemolysis on blood agar.
Streptococcus pyogenes Gram stain
 Streptococci

Strept. pyogenes Viridans streptococci Strept. bovis

Strept. agalactiae Strept. pneumoniae.
 Streptococcus pyogenes
• They are catalase negative
• Streptococcus pyogenes is responsible of
pyogenic infections, toxic and immunological
diseases.
• Streptococcus pyogenes expresses many
potential virulence factors
 virulence factors of Strept. pyogenes
• 1- Adherence (colonization) surface macromolecules they
include M protein
• 2- Enhancement of spread in tissues:
• Hyaluronidase or spreading factor: hydrolyses hyaluronic acid
in host tissues.
• Streptokinase: activates plasminogen to form plasmin cause
lyses of fibrin in clots and thrombi.
• Evasion of phagocytosis by capsule production ,leukocidins
,streptolysin and nucleases.
• Production of exotoxins and other systemic effects such as
• Pyogenic Toxin A responsible for streptococcal toxic shock
syndrome
• Exotoxin B: is a protease produced in large amounts that
rapidly destroy tissue causing necrotizing fasciitis.
 Strept.pyogenes
• Pathogenesis: Streptococcus pyogenes one of
the causes of suppurative and toxigenic
diseases.
• Source of infection: endogenous or
exogenous
 Diseases caused by Strept.pyogenes
1- Suppurative diseases
i.e. active infections associated with production of pus, occur
skin, and systemically.
• Skin: could be in the form of
• Cellulitis infection in subcutaneous tissues
• Erysipelas: Acute superficial cellulitis of skin with lymphatic
involvement; face and lower extremities. There is fever and
systemic toxicity.
• Necrotizing fasciitis involves infection of the fascia and may
proceed rapidly to underlying muscle causing severe tissue
destruction. The organisms causing this diseases are known
as flesh-eating bacteria.
• Bacteremia: bacteria in the blood with mortality 40% or
Septicemia (sepsis)
 Diseases caused by Strept.pyogenes
• 2-Systemic toxigenic diseases:
• Streptococcal toxic shock syndrome : is
caused by a few strains .The infection starts
with minor soft tissue infection and rapidly
progressive shock and multiorgan failure.
 Diagnosis of Strept.pyogenes
• Specimen taken could be wound and blood
• Direct examination:
• Gram positive cocci arranged in pairs or chains
• Latex agglutination test by group A antibody
• Direct culture on blood agar, the culture shows
small, beta-hemolytic colonies.
• Blood cultures are done in cases associated with
bacteremia or septicemia e.g necrotizing fasciitis
Non fermentative Gram negative bacilli
Pseudomonas
• These bacteria are common inhabitants of soil
and water.
• It is an opportunistic pathogen can cause a
variety of systemic infections, particularly in
patients with severe burns and in
immunosuppressed patients .
• Pseudomonas aeruginosa is the fourth most
commonly-isolated nosocomial pathogen
accounting for 10% all hospital-acquired
infections.
•
 Pseudomonas aeruginosa
• They are Gram-negative bacilli, motile, non-
spore forming ,aerobic
• It needs simple nutritional requirements.
• Produce soluble exopigments: a yellow
pigment pyoverdin and the blue pigment
pyocyanin,both combined to form green
colour characteristic of P.aeruginosa.
 Pseudomonas aeruginosa
• Virulence factors include: pili, polysaccharide capsule,
endotoxin, exotoxin A, leukocidin.
• Resistance: P.aeruginosa is resistant to high
concentrations of salts and dyes, to weak antiseptics,
and antibiotics.
Resistanse of P. aeruginosa to antibiotics is by
plasmids,formation of biofilm and permeability barrier
afforded by its outer membrane LPS.
• Pathogenesis:
 The organism cause pyogenic infection. "Blue pus" is a
characteristic of suppurative infections caused by
P.aeruginosa and is due to the exopigment pyocyanin
produced by the organism.
 Pseudomonas infections are both invasive and toxigenic.
 Pseudomonas aeruginosa
• Diseases: Infections occur in the following organs:
• Skin and soft tissue infections: Wound infections and
dermatitis.
• Bacteremia and septicemia: Usually hospital acquired
occur mostly in immuno-compromised and severe
burns .
• Laboratory diagnosis: It is identified on the basis of its
• Gram morphology
• growth at 42°
• Fluorescence under ultraviolet light is helpful in early
identification of P. aeruginosa in wounds.
 Pseudomonas aeruginosa
• Epidemiology and control
• Pseudomonas aeruginosa is a common inhabitant
on skin of some healthy persons, throat and
stool of non-hospitalized patients.
• Within the hospital, P. aeruginosa finds numerous
reservoirs such as disinfectants, respiratory
equipment. Spread occurs from patient to patient
on the hands of hospital personnel, or by contact
with contaminated reservoirs.
• The spread of P. aeruginosa can best be
controlled by infection control precautions.
 Anaerobic spore forming Gram
positive bacilli
• Clostridium They are large, gram-positive bacilli, spore
forming organisms.
• Vegetative forms of Clostridia are strictly anaerobes
present in soils and the intestinal tracts of animals.
• Being spore forming they can survive in the
environment for many years.
• They are considered as opportunistic pathogens.
• It include C.perfringens with other Clostridium causing
gas gangrene and C.difficile.
• Also, they include C.tetani and C.botulinum that
produce the most potent biological toxins known to
humans.
Clostridium perfringens
 Clostridium perfringens
• Gram-positive large bacilli ,non-motile and
anaerobic.
• Biochemical reaction:
– Fermentation of sugar with production of large amount
of acid and gas this is detected by stormy clot
fermentation test .
– Production of a lecithinase,α-toxin, that precipitate the
lipid content of the media .The enzyme is detected by
Nagler reaction where colonies are surrounded by
opaque zones when cultured on serum media or egg
yolk media .
 Clostridium perfringens
• Pathogenicity determinants :C.perfringens produce
• Lecithinase, (phospholipase C) which the primary
virulence factor. The toxin hydrolyze lecithin (phopholipids)
of host cells and is responsible for gas gangrene and
myonecrosis in infected tissues.The toxin is also hemolytic.
• Theta toxin has hemolytic and rapid necrotizing effect but
it is not lecithinase. It induces inflammatory mediators
(cytokines),necrosis factor, platelet activating factor which
may lead to shock.
• Extracellular enzymes: neuraminidase, proteases,
lipases,collagenase and hyaluronidase are spreading factor.
Clostridium perfringens
 Clostridium clinical diseases
1- Gas gangrene
Gas gangrene or Clostridial myonecrosis:is a bacterial
infection that produces swelling of tissues due to release of
gas, as a fermentation products.
• The incubation period of the disease is 1-6 days.
• It is fatal.
• Two groups of Clostridia are responsible for the disease:
• Saccharolytic Clostridium which include:
C.perfingens,C.novyi and C.septicum
• Proteolytic Clostridium which include: C.histolyticum,
C.bifermentans and C.fallax
 Pathogenesis of gas gangrene
• Clostridia grow in deep severely lacerated wound after soil or
intestinal tract contamination.
• The impaired blood supply due to trauma, foreign bodies or surgery
creates an anaerobic environment that favours the growth of
Clostridia.
• The organism produces several tissue degrading enzymes including
lecithinase (alpha toxin), proteolytic and saccharolytic enzymes.
• This result in necrosis and destruction of blood vessels and the
surrounding muscles.
• The abundant production of gas reduces blood supply by pressure
effect.
• All these factors create an anaerobic environment in adjacent tissue
and the organism spreads systemically and cause toxaemia.
• Clostridial septicemia can lead to severe shock with massive
haemolysis and renal failure.
 Clinical findings in gas gangrene
• The incubation period is from 1-6 days.
• Fever, pain, edema and cellulitis occur in the
wound area. Infected muscle changes its color,
become oedematous.
• There is foul-smell discharge, and crepitations
that indicate the presence of gas in tissue.
• Shock can result with high mortality rate
 Clostridium clinical diseases
2- Other forms of tissue infections include:
• Cellulitis with gradual onset and no toxaemia.
The infecting organisms invade only dead
tissue with no spread of infection.It has good
prognosis.
• Superficial wound contamination: The least
serious infections, involves only necrotic
tissue. It is caused by C.perfringens, with
Staphylococci or Streptococci.
 Laboratory diagnosis:
• .The disease is a medical emergency, for this reason
treatment should start once clinically diagnosed
• Direct laboratory examination results should be
delivered immediately.
• Specimen: Swabs are collected in a special transport
media.
– Direct examination:Large Gram positive bacilli,with
absence of phagocytic cells being destructed by toxins.
– Culture: are done under aerobic and strict anaerobic
conditions at 37ºC for 48 hours. Colonies isolated from
anaerobic culture are identified by morphology, culture on
egg yolk agar and biochemical reactions.
 Treatment:
• Early diagnosis and aggressive treatment are
essential to prevent amputation and death.
•
• Surgical debridement removal of necrotic tissue is
essential to expose tissue to aerobic condition.
• Antibiotic treatment includes:Penicillin G in high
doses and clindamycin.
• Alpha anti-toxin antiserum.
• Hyperbaric oxygen (dive chamber)is an additional
therapy.
 Clostridium tetani
• It is the causative agent of tetanus. The organism is
found in heavily-manured soils, in the intestinal tracts
and feces of various animals.Carrier rates in humans
vary from 0 to 25%, and the organism is a transient
intestinal flora.
• Morphology: Gram-positive,long thin motile
bacilli,produces bulging terminal spores giving it a
distinctive drumstick appearance.
• Culture: It is a strictly anaerobe,grow on blood agar or
cooked meat medium.
• Antigenic structure: Single antigenic toxin is found in
all strains.
Clostridium tetani
 Clostridium tetani
• Pathogenicity determinant:
– Tetanospasmin: systemic-acting,plasmid-mediated A-
B neurotoxin. The B domain is responsible for binding
of the toxin to host cell neurons, and the A fragment is
responsible for the neurotoxicity of the toxin. Binding
is irreversible event. Tetanospasmin, acts centrally at
the level of the anterior horn cells of the spinal cord.
The effect of the toxin is to block the release of
inhibitory neurotransmitters.
• Tetanolysin:hemolysin,may be important in local
infection
 Tetanus
• It is a serious clinical disease because it is
difficult to reverse, with a mortality rate of
50%. A small lethal dose is sufficient to cause
the disease.The incubation period depend on
the distance of the infection site from the
central nervous system, it varies from 3-10
days .
• Most cases of tetanus result from small deep puncture wounds or
lacerations which become contaminated with C. tetani spores that
germinate and produce toxin.
• The bacteria remain localized at the site of introduction with minimal
inflammation.
• Tetanospasmin produced binds to peripheral nerve terminals and
transported within the axon and across synaptic junctions until it reaches
the central nervous system; the spinal cord and brain stem (anterior horn
cells) .
• It becomes rapidly fixed to gangliosides at the presynaptic inhibitory
motor nerve endings, and is taken up into the axon by endocytosis.
• The effect of the toxin is to block the release of inhibitory
neurotransmitters; glycine and gamma-amino butyric acid; across the
synaptic cleft, which is required to check the nervous impulse thus
producing generalized muscular spasms characteristic of tetanus.
 Clinical forms of tetanus
•
• Generalized tetanus:There is severe painful spasms and
rigidity of the voluntary muscles.The characteristic
symptom of "lockjaw" or "trismus" involves spasms of the
muscle of the face.It is an early symptom which is followed
by progressive rigidity and violent spasms of the trunk and
limb muscles. Spasms of pharyngeal muscles cause
difficulty in swallowing. Death usually results from
interference with the mechanics of respiration.
•
• Localized tetanus: Rare,there is localized muscle
contractions in the area of infection. It is not fatal
 Tetanus
•
• Laboratory diagnosis: Diagnosis is clinical and
treatment should start to stop production and
absorption of toxin. Bacteria are isolated from wounds
in a minority of cases
•
• Specimen: Deep wound swab
•
• Direct examination:Gram stain smears revealed gram positive
bacilli with terminal bulging spore,drumstick.
• Culture: Done under anaerobic condition, on blood agar for 48-
72hours. Colonies producing beta hemolysis are identified by gram
stain.
 Tetanus
• Treatment:
• Passive immunization: Human tetanus immunoglobulin
(HTIG) is administered to neutralize the toxin before it
binds to the tissue.The anti-toxin is injected
intramuscularly (at a dose of 500-6000 IU).
• Surgical debridement of the necrotic tissue is essential.
• C.tetani infection can be treated with penicillin and
metronidazole
• Muscle relaxants, sedation and assisted ventilation are
supportive therapy.
 Non-spore forming anaerobes

• Strict anaerobes form 95-99% of gastrointestinal flora ,they

are also found in the mouth and genitourinary tract.
• Certain organisms produce opportunistic infections, the
source of which is endogenous.
• Bacteroides fragilis :
• They are gram-negative bacilli .
• produce a very large poly-saccharide capsule involved in
pathogenesis since it is antiphagocytic and responsible for
abscess formation.
• They grow well on blood agar.
• They are responsible of more than 80% of all intra-abdominal
infections