Review Of Literature

Review
Of
Literature

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 Review Of Literature

3. REVIEW OF LITERATURE:

3.1. HISTORICAL BACKGROUND:

Although treatment of infection has been a fundamental piece of the surgeon’s

practice since the dawn of time, the body of knowledge that prompted the
present field of careful irresistible ailment was gotten from the advancement of
germ hypothesis and antisepsis. Application of the last to clinical practice,
simultaneous with the improvement of anesthesia, was urgent in enabling
specialists to extend their collection to envelop complex systems that already
were related with incredibly high rates of unpleasantness and mortality because
of postoperative diseases. However, until recently the occurrence of
contamination identified with the surgical wound was the standard as opposed
to the special case.
In fact, the development of modalities to effectively prevent and treat infection
has occurred only within the most recent quite a few years. Various perceptions
by nineteenth century doctors and specialists were basic to our present
comprehension of the pathogenesis avoidance and treatment of surgical
infections. In 1846 I.S. a magyar doctor, took a post in Vienna. He saw that the
mortality from puerperal ("childbed") fever was a lot higher in the showing
ward (1:11) than in the ward where patients were conveyed by birthing
assistants (1:29). He likewise mentioned the fascinating objective fact that
ladies who conveyed preceding entry on the encouraging ward had an
insignificant death rate.
The grievous demise of an associate because of overpowering contamination
after a blade scratch got during a dissection of a lady who had kicked the bucket
of puerperal fever drove Semmelweis to see that pathologic changes in his
companion were indistinguishable from those of ladies biting the dust from this
baby blues infection. He at that point estimated that puerperal fever was brought
about by foul material transmitted from patients passing on of this sickness via

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carriage on the looking at fingers of the restorative understudies and doctors

who every now and again went from the post-mortem examination space to the
wards. The low mortality noted in the midwives’ ward, Semmelweis realized,
was because midwives did not participate in autopsies.
Fired with the zeal of his revelation, he posted a notice on the entryway to the
ward requiring all parental figures to wash their hands completely in chlorine
water prior to entering the area. This basic mediation diminished mortality from
puerperal fever to 1.5%, outperforming the record of the maternity specialists.
In 1861, he distributed his great work on childbed fever dependent on records
from his training. Unfortunately, Semmelweis’ ideas were not well accepted by
the authorities of the time. (Nuland SB. et al., 2003)
Increasingly frustrated by the indifference of the medical profession, he began
writing open letters to well-known obstetricians in Europe, and was committed
to an asylum due to concerns that he was losing his mind. He died shortly
thereafter. His achievements were only recognized after Pasteur’s description of
the germ theory of disease. Louis Pasteur played out an assortment of work
during the last piece of the nineteenth century that gave the underpinnings of
present day microbiology, at the time known as "germ speculation." Using this
principle he developed techniques of sterilization critical to oenology, and
identified several bacteria responsible for human illnesses, including
Staphylococcus and Streptococcus pneumoniae (pneumococcus).
Joseph Lister, the son of a wine merchant, was appointed professor of surgery at
the Glasgow Royal Infirmary in 1859. In his early practice, he noted that over
50% of his patients undergoing amputation died because of postoperative
infection. After hearing of Pasteur’s theory, Lister experimented with the use of
a solution of carbolic acid, which he knew was being used to treat sewage. He
originally detailed his discoveries to the British Medical Association in 1867
utilizing dressings soaked with carbolic corrosive on 12 patients with compound

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cracks; 10 recouped without removal, one survived with amputation, and one
died of causes unrelated to the wound. In spite of initial resistance, his methods
were quickly adopted throughout Europe.
From 1878 until 1880, Robert Koch was the District Medical Officer for
Wollstein, which was an area in which anthrax was endemic. Performing tests
in his home, without the advantage of logical gear and scholarly contact, Koch
created systems for culture of Bacillus anthracis and demonstrated the capacity
of this creature to cause Bacillus anthracis in sound creatures.
He built up the accompanying four proposes to recognize the relationship of life
forms with explicit sicknesses: (a) the speculated pathogenic life form ought to
be available in all instances of the ailment and missing from solid creatures, (b)
the presumed pathogen ought to be detached from an ailing host and developed
in an unadulterated culture in vitro, (c) cells from a pure culture of the suspected
organism should cause disease in a healthy animal, and (d) the organism should
be reisolated from the newly diseased animal and shown to be the same as the
original.
He used these same techniques to identify the organisms responsible for cholera
and tuberculosis. During the following century, Koch's hypothesizes, as they
came to be called, wound up basic to our comprehension of careful
contaminations and remain so today. (Wangensteen OH et al., 1978)
The first intra-stomach task to treat disease through "source control" (i.e.,
careful intercession to dispose of the wellspring of disease) was appendectomy.
This activity was spearheaded by Charles McBurney at the New York College
of Physicians and Surgeons, among others.(Rutkow E.et al., 1998)
Sir Alexander Fleming, subsequent to serving in the British Army Medical
Corps during World War I, proceeded with work on the characteristic
antibacterial activity of the blood and germicides. In 1928, while examining flu
infection, he noticed a zone of hindrance around a shape province

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(Penicilliumnotatum) that fortunately developed on a plate of Staphylococcus,

and he named the dynamic substance penicillin. This first powerful antibacterial
specialist consequently prompted the improvement of several strong
antimicrobials, set up for their utilization as prophylaxis against postoperative
disease, and turned into a basic part of the armamentarium to treat forceful,
deadly careful contaminations. Simultaneous with the improvement of various
antimicrobial operators were propels in the field of clinical microbiology.
Numerous new organisms were recognized, including various anaerobes; the
autochthonous microflora of the skin, gastrointestinal tract, and different pieces
of the body that the specialist experienced during the time spent an activity were
described in extraordinary detail. In any case, it stayed hazy whether these life
forms, anaerobes specifically, were commensals or pathogens. In this way, the
underlying clinical perceptions of specialists, for example, Frank Meleney,
William Altemeier, and others gave the key, when they saw that aerobes and
anaerobes could synergize to cause genuine delicate tissue and extreme intra-
stomach infection. (Meleney F et al., 1931, Altemeier WA. Et al., 1976)
Thus, the ideas that occupant organisms were nonpathogenic until they entered
a clean body cavity at the season of medical procedure, and that many, if not
most, careful contaminations were polymicrobial in nature, wound up basic
thoughts, and were declared by various clinician-researchers in the course of the
last a few decades. (Bartlett JG et al., 1995, Dunn DL et al., 1984)

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3.2 PATHOGENESIS OF INFECTION

Host Defenses

The mammalian host has a few layers of endogenous barrier systems that serve
to limit multiplication of organisms inside the host, and destroy attacking
microorganisms. These barriers work as a complex, exceedingly controlled
framework that is amazingly powerful in adapting to microbial trespassers.
Passage of organisms into the mammalian host is blocked by the nearness of
various boundaries that have either an epithelial or mucosal surface.

The most extensive physical barrier is the skin. Notwithstanding the physical
barrier presented by the epithelial surface, the skin harbors its very own
occupant microflora that may inhibit the connection and intrusion of
noncommensal microorganisms. Microbes are also held in check by chemicals
that sebaceous glands secrete and by the constant shedding of epithelial cells.

The respiratory tract has a few host resistance that support to maintain sterility
in the distal bronchi and alveoli under typical conditions. In the URT,
respiratory bodily fluid catch bigger particles, including organisms. This bodily
fluid is then passed into the upper aviation routes and oropharynx by ciliated
epithelial cells, where the bodily fluid is cleared by means of hacking. Littler
particles landing in the LRT are cleared by means of phagocytosis by alveolar
macrophages. Any procedure that reduces these host protections can prompt
improvement of bronchitis or pneumonia. (Dunn DL et al., 1990)

Microorganisms quickly experience a progression of host safeguard systems

that dwell inside most by far of tissues of the body. These include resident
macrophages and low levels of complement (C) proteins and immunoglobulins
(e.g., antibodies).(Van Till JW et al., 2007)

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Figure 1: Pathogenesis of SSI

3.3 MICROBIOLOGY OF INFECTIOUS AGENTS

A partial list of common pathogens that cause infections in surgical patients is

provided in Table no. 1.

Bacteria

Bacteria are responsible for the majority of surgical infections. The Gram’s
stain is an important evaluation that allows rapid classification of bacteria by
color. This color is related to the staining characteristics of the bacterial cell
wall: Gram positive bacteria stain blue and Gram negative bacteria stain red.
Microbes are characterized dependent on some of extra qualities, including
morphology (cocci and bacilli), the pattern of division (e.g., single organisms,
groups of organisms in pairs [diplococci], clusters [staphylococci], and chains
[streptococci]), and the presence and location of spores.

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Gram-positive bacteria that mostly cause infections in surgical patients include

aerobic skin commensals and enteric organisms. Aerobic skin commensals
cause a large percentage of surgical site infections (SSIs), either alone or in co-
occurrence with other pathogens; enterococci can cause nosocomial infections
(UTI and bacteremia) in immuno-suppressive or chronically ill patients, but are
of relatively low virulence in healthy individuals.

There are numerous pathogenic Gram-negative bacterial species that are

equipped for causing disease in surgical patients. Most Gram-negative organism
forms important to the specialist are bacilli having a place with the family
Enterobacteriaceae. Other Gram-negative bacilli of note incorporate
Pseudomonas spp., including Pseudomonas aeruginosa and fluorescence and
Xanthomonas spp. Anaerobes are the predominant indigenous flora in many
areas of the human body, with the particular species being dependent on the
site. For example, Propionibacterium acnes and other species are a major
component of the skin microflora and cause the infectious manifestation of
acne.

As noted previously, large numbers of anaerobes contribute to the microflora of

the oropharynx and colon. Infection due to Mycobacterium tuberculosis was
once one of the most common causes of death in Europe in the seventeenth and
eighteenth centuries. This organism and other related organisms (M avium-
intracellulare and M. leprae) are known as acid-fast bacilli. Other acid-fast
bacilli include Nocardia spp. These organisms typically are slow growing.

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Fungi

Organisms of importance to specialists incorporate those that reason nosocomial

contaminations in careful patients as a major aspect of polymicrobial diseases or
fungemia (e.g., Candida albicans and related species), uncommon reasons for
forceful delicate tissue contaminations (e.g., Mucor, Rhizopus, and Absidia
spp.), and so-called opportunistic pathogens that cause infection in the immuno
suppressive host (e.g., Aspergillusfumigatus, niger, terreus, and other spp.).

Viruses

So also to numerous contagious diseases, most clinically applicable viral

contaminations in surgical patients happen in the immuno suppressive off host,
especially those getting immunosuppression to anticipate rejection of a strong
organ allograft. Significant infections incorporate adenoviruses,
cytomegalovirus, Epstein-Barr infection, herpes simplex infection, and
varicella-zoster infection. Specialists must know about the appearances of
hepatitis B and C infection, just as human immunodeficiency infection diseases,
including their ability to be transmitted to health care worker.

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Table no. 1- Common Pathogens in Surgical Patients

Gram-positive aerobic cocci

Staphylococcus aureus
Staphylococcus epidermidis
Streptococcus pyogenes
Streptococcus pneumonia
Enterococcus faecium, E. faecalis
Gram-negative aerobic bacilli
Escherichia coli
Haemophilus influenza
Klebsiella pneumonia
Proteus mirabilis
Enterobacter cloacae, E. aerogenes
Serratiamarcescens
Acinetobactercalcoaceticus
Citrobacterfreundii
Pseudomonas aeruginosa
Xanthomonasmaltophilia
Anaerobes Gram-positive
Clostridium difficile
Clostridium perfringens, C. tetani, C. septicum
Peptostreptococcus spp.
Gram-negative
Bacteroidesfragilis
Fusobacterium spp.
Other bacteria

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Mycobacterium avium-intracellulare
Mycobacterium tuberculosis
Nocardia asteroids
Legionella pneumophila
Listeria monocytogenes
Fungi
Aspergillusfumigatus, A. niger, A. terreus, A. flavus
Blastomycesdermatitidis
Candida albicans
Candida glabrata, C. paropsilosis, C. krusei
Coccidiodesimmitis
Cryptococcus neoformans
Cryptococcus neoformans
Histoplasmacapsulatum
Mucor/Rhizopus
Viruses
Cytomegalovirus
Epstein-Barr virus
Hepatitis A, B, C viruses
Herpes simplex virus
Human immunodeficiency virus
Varicella zoster virus

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3.4 INFECTIONS OF SIGNIFICANCE IN SURGICAL PATIENTS

Surgical Site Infections

Surgical site infections (SSIs) are infections of the tissues, organs, or spaces
visible by surgeons during performance of an invasive procedure. Risk factors
for improvement of SSIs listed (Table no.2). Surgical wounds are classified
based on the assumed size of the bacterial load at the time of surgery (Martone
WJ et al., 2001). SSIs are classified into incisional SSIs, which can be superficial

or deep, and organ/space SSIs, which affect the rest of the body other than the
body wall layers. These classifications are defined as follows:
Intra-Abdominal Infections - IAI is a broad term that encompasses a number of

infectious processes, including peritonitis, diverticulitis, cholecystitis,

cholangitis, and pancreatitis. A common cause of IAI is appendicitis.

Organ-Specific Infections - Infection involves any part of the organs and spaces

other than the incision, which was opened or operated during operation.

Infections of the Skin and Soft Tissue - Involves only skin and subcutaneous tissue

of incision.

Although randomized trials have not been performed, it is recommended that

clinicians maintain appropriate blood sugar control in patients in the
perioperative period to minimize the occurrence of SSI. The respective effects
of body temperature and the level of inhaled oxygen during surgery on SSI rates
also have been studied, and both hypothermia and hypoxia during surgery are
associated with a higher rate of SSIs. In spite of the fact that an underlying
examination gave proof that patients who got large amounts of breathed in
oxygen during colorectal medical procedure created less SSIs. (Greif R et al.,
2000)

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Table no. 2 Risk Factors for Development of Surgical Site Infections

TOLERANT FACTORS OPERATION FACTORS

Boundaries of age Preoperative shaving

Poor wholesome state Length of activity

Diabetes mellitus or renal Remote material in surgical site

disappointment

Smoking Addition of careful channel

Coinciding disease at other site Lacking instrument disinfection

Immunosuppression Poor conclusion

Long post-usable stay Post-usable hypothermia

Post-usable hetman or lymphatic break
Site of strategy (e.g. at a skin wrinkle)

Table no. 3 Wound Class, Representative Procedures, and Expected

Infection Rates

WOUND CLASS EXAMPLES OF CASES EXPECTED

INFECTION RATES
Clean (class I) Hernia repair, breast 1%–2%
biopsy sample
Clean/contaminated Cholecystectomy, elective 2.1%–9.5%
(class II) Gastro Intestinal surgery
(not colon)
Clean/contaminated Colon surgery 4%–14%
(class II)
Contaminated (class III) Trauma in abdomen, 3.4%–13.2%
tissue injury, enterotomy
Dirty (class IV) Perforated diverticulitis, 3.1%–12.8%
necrotizing tissue
infections
3.5 Postoperative Nosocomial Infections
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Surgical patients are inclined to build up a wide assortment of nosocomial

contaminations during the postoperative period, which incorporate SSIs, UTIs,
pneumonia, and bacteremia. SSIs are talked about before, and the last sorts of
nosocomial contaminations are identified with delayed utilization of inhabiting
cylinders and catheters with the end goal of urinary seepage, ventilation, and
venous and blood vessel get to, separately. Postoperative surgical patients
should have indwelling urinary catheters removed as quickly as possible,
typically within 1 to 2 days, as long as they are movable, to avoid the
development of a UTI.

Prolonged mechanical ventilation is associated with nosocomial pneumonia.

These patients present with more severe disease, are more likely to be infected
with drug-resistant pathogens, and suffer increased mortality compared to
patients who develop community-acquired pneumonia. (Klompas M et al., 2007)

Surgical patients should be remove from mechanical ventilation as soon as

workable, based on oxygenation and inspiratory effort, as prolonged mechanical
ventilation increases the risk of nosocomial pneumonia. Duration of
catheterization, insertion or manipulation under emergency or non-sterile
conditions, use for hyper alimentation and the use of multi lumen catheters
increase the risk of infection.

Use of a central line insertion protocol that includes full barrier precautions and
chlorhexidine skin prep has been shown to decrease the incidence of infection.
(O’Grady NP et al., 2011)

Use of systemic antibacterial or antifungal agents to prevent catheter infection is

of no utility and is contraindicated.

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3.6 PREVENTION AND TREATMENT OF SURGICAL INFECTIONS

General Principles

Hand decontamination (general) as described previously, the host resident

microflora of the skin (patient and surgeon) and other barrier surfaces represent

a potential source of microbes that can invade the body during trauma, thermal

injury, or elective or emergent surgical intervention. For this reason, operating

room personnel are versed in mild mechanical exfoliation of the skin of the

hands and forearms using antibacterial preparations, and the intraoperative

aseptic technique is employed. Similarly, application of an antibacterial agent to

the skin of the patient at the proposed operative site takes place prior to creating

an incision. Also, if necessary, hair removal should take place using a clipper

rather than a razor; the latter promotes overgrowth of skin microbes in small

nicks and cuts. Dedicated use of these modalities clearly has been shown to

diminish the quantity of skin microflora, and although a direct correlation

between praxis and reduced infection rates has not been demonstrated,

comparison to infection rates prior to the use of antisepsis and sterile technique

makes clear their utility and importance. The aforementioned modalities are not

capable of sterilizing the hands of the surgeon or the skin or epithelial surfaces

of the patient, although the inoculum can be reduced considerably. Thus, entry

through the skin, into the soft tissue, and into a body cavity or hollow viscus

invariably is associated with the introduction of some degree of microbial

contamination. For that reason, patients who undergo procedures that may be
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associated with the ingress of significant numbers of microbes (e.g., colonic

resection) or in whom the consequences of any type of infection due to said

process would be dire (e.g., prosthetic vascular graft infection) should receive

an antimicrobial agent.

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