Surgical Infections Practice Questions

Q: The indications for surgery in patients with pulmonary tuberculosis include all of the following except

AFB positive sputum with normal chest CT scan. ***AFB positive sputum with normal chest CT scan*** - This scenario typically indicates **early or uncomplicated pulmonary tuberculosis** that is responsive to standard antitubercular drug therapy. - A normal chest CT scan suggests the absence of significant cavitations, extensive lung damage, or other structural abnormalities that would necessitate surgical intervention. *Drug-resistant chronic tuberculous abscess* - **Drug resistance** and the presence of a **chronic tuberculous abscess** make medical management difficult and often ineffective. - Surgical resection can remove the source of infection, facilitate cure, and prevent further dissemination of drug-resistant organisms. *Severe life-threatening haemoptysis* - **Severe or life-threatening haemoptysis** in TB patients often arises from eroded pulmonary vessels within cavitary lesions. - Surgical intervention (e.g., lobectomy, pneumonectomy) is critical to control bleeding and prevent fatal outcomes when conservative measures fail. *Aspergilloma within a tuberculous cavity with recurrent haemoptysis* - An **aspergilloma (fungal ball)** developing in a pre-existing tuberculous cavity can cause **recurrent haemoptysis** due to erosion of blood vessels by the fungus. - Surgical resection is often the definitive treatment to remove the aspergilloma and prevent further bleeding.

Q: A 75 year old diabetic man had surgery for perforated colonic diverticulitis. In his post operative period he complained of severe wound pain and had signs of spreading inflammation with crepitus with subdermal spread of gangrene. He is likely to be suffering from

Clostridial infection. ***Clostridial infection*** - The rapid onset of **severe wound pain**, **spreading inflammation**, **crepitus** (due to gas production), and **subdermal spread of gangrene** in a diabetic patient post-surgery for perforated diverticulitis is highly suggestive of **gas gangrene**, most commonly caused by **Clostridium** species. - **Diabetes** and a surgical wound involving the colon (a source of clostridia) are significant risk factors for such infections. *Abdominal wall cellulitis* - **Cellulitis** is a superficial infection of the skin and subcutaneous tissue, typically presenting with redness, warmth, and tenderness, but often lacks the rapid progression, **severe pain**, **crepitus**, and **gangrene**. - While an inflammatory process, it does not explain the presence of **crepitus** or the rapid, destructive tissue necrosis described. *Intra-peritoneal collection* - An **intra-peritoneal collection** (e.g., abscess) would primarily affect the abdominal cavity and usually present with localized abdominal pain, fever, and possibly ileus, but not typically with **crepitus** and **spreading gangrene** in the abdominal wall wound. - Such collections are often identified by imaging (CT scan) and do not directly cause the described severe wound infection signs. *Meleney synergistic gangrene* - **Meleney synergistic gangrene**, also known as progressive bacterial synergistic gangrene, is a chronic, progressive, and painful infection often seen around surgical incisions, characterized by a central area of necrosis and surrounding erythema. - While it involves gangrene and is painful, it typically has a **slower progression** and is caused by a synergy of aerobic and anaerobic bacteria, rather than the rapid, gas-producing destructive process characteristic of **clostridial infection**.

Q: Southampton wound grading system and ASEPSIS wound score is used for

Severity of wound infections. ***Severity of wound infections*** - The **Southampton wound grading system** assesses postsurgical wounds for complications like seroma, hematoma, and infection. - The **ASEPSIS wound score** is used for the objective assessment of **surgical site infections (SSI)**, considering factors like additional treatment, serous discharge, erythema, pus, separation of deep tissues, isolation of bacteria, and duration of hospital stay. *Surgical scar* - While wound healing can impact scars, these systems are primarily concerned with **acute wound complications and infection**, not the long-term cosmetic outcome of the scar itself. - Scar evaluation often uses different scales, such as the Manchester Scar Scale or the Vancouver Scar Scale, which focus on attributes like color, vascularity, pliability, and height. *Surgical site cosmesis* - This refers to the **aesthetic appearance** of the surgical site, which is a different aspect from infection status and complications. - Cosmesis is evaluated subjectively or using specific scar scales, not the Southampton or ASEPSIS scores. *Severity of granulation tissue* - Granulation tissue is a sign of **healing**; its severity is not the primary focus of these grading systems, which are designed to detect and quantify complications and infections. - While excessive or poor granulation can indicate issues, these systems broadly categorize wound issues rather than specifically grading granulation tissue.

Q: Hilton's method of Incision and drainage of abscess has the advantage of:

Avoids injury to underlying vessels and nerves. ***Avoids injury to underlying vessels and nerves*** - Hilton's method involves blunt dissection with an artery forceps once the skin incision is made, allowing the surgeon to **feel important structures** and push them aside. - This technique is particularly useful in areas with **numerous neurovascular bundles**, such as the axilla or neck, minimizing the risk of iatrogenic damage. *Complete drainage of pus* - While Hilton's method facilitates drainage, it doesn't inherently guarantee **complete drainage** more than other proper incision and drainage techniques. - The effectiveness of drainage primarily depends on the **size and location of the incision** relative to the abscess cavity. *Heals without scar* - Any surgical incision, including those made using Hilton's method, will result in some degree of **scar formation**. - The method prioritizes safety over cosmetic outcomes, and the nature of the scar depends on **wound healing** and **surgical closure**. *Provides irrigation* - Irrigation is a separate step often performed after the incision and drainage to **flush out debris** and reduce bacterial load. - Hilton's method itself is a technique for making the incision and gaining access to the abscess, not for **intraoperative irrigation**.

Q: Following are the factors for increased risk of wound infection EXCEPT:

Good blood supply. ***Good blood supply*** - A **robust blood supply** is crucial for wound healing as it delivers **oxygen, nutrients, and immune cells** to the injured site, actively preventing infection. - Good perfusion means that the tissues can effectively **clear bacteria** and support the local immune response, thereby **decreasing the risk** of wound infection. *Metabolic diseases (diabetes, uraemia)* - **Diabetes** impairs wound healing through mechanisms like **peripheral neuropathy**, **vasculopathy**, and compromised immune function, greatly increasing infection risk. - **Uraemia** in kidney failure leads to a buildup of toxins that can **suppress the immune system** and impair cellular function, making patients more susceptible to infections. *Immunosuppression* - **Immunosuppression**, whether due to chronic illness, medications (e.g., corticosteroids), or immunodeficiency, significantly **weakens the body's defense mechanisms**. - A compromised immune system is less able to **identify, target, and eliminate invading pathogens**, leading to a higher incidence of wound infections. *Malnutrition* - **Malnutrition**, particularly deficiencies in protein, vitamin C, and zinc, can severely **impair collagen synthesis**, immune function, and overall tissue repair. - Inadequate nutritional status hinders the body's ability to **mount an effective immune response** and regenerate tissues, creating an environment ripe for infection.

Q: A 20-year-old patient underwent open hernia surgery four days ago. He has had fever for the last day and on local examination the operated site was wet with pus and surrounding redness and edema. The appropriate management would be:

Opening sutures and cleaning of wound. ***Opening sutures and cleaning of wound*** - The presence of **fever**, **pus**, **redness**, and **edema** indicates a **surgical site infection (SSI)** with abscess formation, necessitating immediate **wound exploration** and **drainage**. - **Opening the sutures** allows for complete removal of pus, debridement of necrotic tissue, and proper irrigation, which are critical steps in managing a deep-seated infection. *Sending pus for C/S* - While **culture and sensitivity (C/S)** is important for guiding antibiotic therapy, it does not address the immediate mechanical problem of pus accumulation. - Delaying drainage for C/S results would allow the infection to spread, causing further tissue damage. *Daily dressing* - **Daily dressing** alone is insufficient for a wound with active infection and pus accumulation; it cannot effectively drain the infection. - Though necessary as part of wound care, it needs to be preceded by effective drainage. *Change of antibiotics* - Changing **antibiotics** without addressing the underlying source of infection (the pus collection) will likely be ineffective as antibiotics cannot penetrate well into an abscess. - Antibiotics are a crucial adjunct to surgical drainage, not a replacement.

Q: All of the following are risk factors for an increased risk of wound infection EXCEPT:

Hypertension. ***Hypertension*** - **Hypertension** itself is not a direct risk factor for wound infection, unlike conditions that impair immunity, tissue perfusion, or healing. - While uncontrolled hypertension can contribute to broader cardiovascular issues, it does not inherently increase the likelihood of **bacterial contamination** or **impaired immune response** in a wound. *Cancer* - Patients with **cancer** often have compromised immune systems due to the disease itself or as a result of treatments like **chemotherapy** or **radiation**, increasing susceptibility to infections. - **Malnutrition** and overall debilitation associated with advanced cancer can also impair wound healing and immune function. *Jaundice* - **Jaundice** (hyperbilirubinemia) is associated with impaired immune function, particularly a reduction in phagocytic activity and cellular immunity, making patients more prone to infections. - High bilirubin levels can also interfere with **collagen synthesis** and wound tensile strength, contributing to delayed healing and increased infection risk. *Obesity* - **Obesity** is a significant risk factor for wound infection due to poor vascularity of adipose tissue, which leads to reduced oxygen delivery and antibiotic penetration to the wound site. - The presence of large skin folds can also create a **moist environment** conducive to bacterial growth, and increased tension on wound edges can impair healing.

Q: Which one of the following statements regarding Felon is NOT correct?

It is a painless condition. ***It is a painless condition*** - A **felon** is an abscess within the distal phalanx (fingertip) confined by fibrous septa, making it an extremely **painful** and tense infection due to increased pressure. - The severe pain is a hallmark symptom, distinguishing it from a painless condition, and is caused by the pus accumulating in a confined space. *It is common in diabetics* - **Felons** (and other soft tissue infections) are indeed more common in individuals with **diabetes mellitus** due to impaired immune function and compromised circulation. - This makes diabetics more susceptible to infections and can also lead to more severe outcomes. *Incision and drainage is the treatment of choice* - For a **felon**, **surgical incision and drainage** is the primary treatment to relieve pressure, evacuate pus, and prevent serious complications like osteomyelitis or necrosis. - This procedure typically involves a longitudinal or hockey-stick incision to access the infected compartment. *There is infection of the finger tip between specialised fibrous septa* - A **felon** is an infection, typically bacterial, located in the closed compartments of the fingertip's distal pulp, which are separated by **fibrous septa**. - These septa connect the skin to the periosteum, creating multiple small, enclosed spaces that can become acutely infected and filled with pus.

Q: Which one of the following statements is NOT correct regarding Necrotising Soft Tissue infections?

They are monomicrobial in nature. ***They are monomicrobial in nature*** - Necrotizing soft tissue infections (NSTIs) are predominantly **polymicrobial**, involving a mix of aerobic and anaerobic bacteria. - While some cases can be monomicrobial (e.g., due to *Streptococcus pyogenes* or *Clostridium perfringens*), the statement that they *are* monomicrobial is generally false. *Treatment consists of wide local excision and appropriate antibiotics* - This statement is **correct**. **Aggressive surgical debridement** (wide local excision) to remove all necrotic tissue is the cornerstone of treatment for NSTIs. - **Broad-spectrum antibiotics** are also essential to cover the polymicrobial nature of these infections, but they are insufficient without surgical intervention. *Tissue biopsy is required for culture and diagnosis* - This statement is **correct**. While the diagnosis is primarily clinical, **tissue biopsy** for gram stain, culture, and histopathology is crucial for identifying the causative organisms and guiding definitive antibiotic therapy. - This helps differentiate NSTIs from other severe soft tissue infections and improves treatment accuracy. *Crepitus, skin blistering and focal skin gangrene are typical presenting features* - This statement is **correct**. These are classic signs of advanced necrotizing soft tissue infections. - **Crepitus** indicates gas production by bacteria, **skin blistering** (bullae) suggests dermal involvement, and **focal skin gangrene** is a direct sign of tissue necrosis, all pointing to the severity and rapid progression of NSTIs.

Q: Extensive surgical debridement, decompression or amputation may be indicated in the following clinical setting except

Acute thrombophlebitis. ***Acute thrombophlebitis*** - This condition involves inflammation and **thrombosis** of a superficial vein, typically managed with **anticoagulation**, pain relief, and local measures. - Surgical intervention like debridement, decompression, or amputation is generally **not indicated** unless there are severe complications such as infection or extensive tissue necrosis, which are rare. *Acute rhabdomyolysis* - Severe rhabdomyolysis can lead to **compartment syndrome**, necessitating fasciotomy (decompression) to prevent irreversible muscle and nerve damage. - In cases of extensive muscle necrosis, **surgical debridement** may be required to remove non-viable tissue and prevent further systemic complications. *Acute haemolytic streptococcal cellulitis* - While initial management is antibiotics, rapidly progressing necrotizing infections (like **necrotizing fasciitis**, a severe form often caused by *Streptococcus pyogenes*) require **extensive surgical debridement** to remove dead tissue and control the spread of infection. - Delayed debridement can lead to systemic toxicity, limb loss, or death, making aggressive surgical intervention crucial. *Progressive synergistic gangrene* - Also known as **Meleney's gangrene**, this rare but severe soft tissue infection requires aggressive and **extensive surgical debridement** of all necrotic tissue. - The combination of aerobic and anaerobic bacteria creates a progressive, destructive lesion that can necessitate amputation if not adequately controlled by debridement.

Question 1

The indications for surgery in patients with pulmonary tuberculosis include all of the following except

Accepted Answer

AFB positive sputum with normal chest CT scan

Answer

Drug-resistant chronic tuberculous abscess

Answer

Severe life-threatening haemoptysis

Answer

Aspergilloma within a tuberculous cavity with recurrent haemoptysis

Question 2

A 75 year old diabetic man had surgery for perforated colonic diverticulitis. In his post operative period he complained of severe wound pain and had signs of spreading inflammation with crepitus with subdermal spread of gangrene. He is likely to be suffering from

Accepted Answer

Clostridial infection

Answer

Abdominal wall cellulitis

Answer

Intra-peritoneal collection

Answer

Meleney synergistic gangrene

Question 3

Southampton wound grading system and ASEPSIS wound score is used for

Accepted Answer

Severity of wound infections

Answer

Surgical scar

Answer

Surgical site cosmesis

Answer

Severity of granulation tissue

Question 4

Hilton's method of Incision and drainage of abscess has the advantage of:

Accepted Answer

Avoids injury to underlying vessels and nerves

Answer

Complete drainage of pus

Answer

Heals without scar

Answer

Provides irrigation

Question 5

Following are the factors for increased risk of wound infection EXCEPT:

Accepted Answer

Good blood supply

Answer

Metabolic diseases (diabetes, uraemia)

Answer

Immunosuppression

Answer

Malnutrition

Question 6

A 20-year-old patient underwent open hernia surgery four days ago. He has had fever for the last day and on local examination the operated site was wet with pus and surrounding redness and edema. The appropriate management would be:

Accepted Answer

Opening sutures and cleaning of wound

Answer

Sending pus for C/S

Answer

Daily dressing

Answer

Change of antibiotics

Question 7

All of the following are risk factors for an increased risk of wound infection EXCEPT:

Accepted Answer

Hypertension

Answer

Cancer

Answer

Jaundice

Answer

Obesity

Question 8

Which one of the following statements regarding Felon is NOT correct?

Accepted Answer

It is a painless condition

Answer

It is common in diabetics

Answer

Incision and drainage is the treatment of choice

Answer

There is infection of the finger tip between specialised fibrous septa

Question 9

Which one of the following statements is NOT correct regarding Necrotising Soft Tissue infections?

Accepted Answer

They are monomicrobial in nature

Answer

Treatment consists of wide local excision and appropriate antibiotics

Answer

Tissue biopsy is required for culture and diagnosis

Answer

Crepitus, skin blistering and focal skin gangrene are typical presenting features

Question 10

Extensive surgical debridement, decompression or amputation may be indicated in the following clinical setting except

Accepted Answer

Acute thrombophlebitis

Answer

Acute rhabdomyolysis

Answer

Acute haemolytic streptococcal cellulitis

Answer

Progressive synergistic gangrene

Surgical Infections — MCQs

Surgical Infections — MCQs

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