口腔颌面外科学（中山大学）10口腔颌面部感染课件

Oral and maxillofacial infection Liang Yu-jie Department of oral and maxillofacial surgery Guanghua school of stomatology Key points in clinical practice n Anatomy n Clinical manifestation n Antibiotics Basic knowledge n Anatomy n Immunology n Surgery Logic n infection prevents more harmful bacteria from causing intestinal infections vagina: prevents yeasts from overgrowing and causing infections nOther body areas are colonized and infections only occur in immunocompromised people nasopharynx, oropharynx, esophagus, stomach Why do people get sick? nHost Factors age gender ethnicity immune status nutritional status behavior nBalance is Key! Host defenses Local defenses: the first line of defense Clinical manifestation Acute inflammation redness swelling heat pain loss of function purulent infection & putrescent cellulitis Local symptom Chronic inflammation inflammatory proliferation fistula recurrence Local symptom Chronic inflammation can result from Failure to eliminate whatever was causing an acute inflammation An autoimmune response to a self antigen - the immune system attacks healthy tissue, mistaking it (them) for harmful pathogens A chronic irritant of low intensity that persists Local symptom Functions in oral and maxillofacial region swallowing speech respiration mouth opening Local symptom General condition common presence chill, fever, headache, discomfort, tire, anorexia, WBC septicaemia, pyohemia dystrophy hepatic failure，kidney failure septic shock Bacteremias refers to the transient presence in the blood of bacteria because of surgery, which are removed rapidly. oral surgery such as tooth extraction may, in certain conditions, result in the establishment of an infection in a site distant from the site of surgery, that is metastatic spread Septicaemia refers to the chronic presence of bacteria in the blood, usually secondary to an established infection somewhere in the body Diagnosis easy to make a correct diagnosis according to the presence of redness, swelling, heat, pain fluctuance test bacterial culture and antibiotic susceptibility testing Fluctuance test The nature of the pain ? The duration of symptoms? Changes in the nature of the swelling and how fast this change is occurring. Did the swelling begin as a soft mass, or was it consistently firm? Is pain associated with the swelling? historical data collection cellulitis diffused firm, erythematous swelling, resulting from the spread of microorganisms through soft tissue abscess localized cavity lined by fibrous connective tissue that contains pus Characteristic Edema(inoculation) Cellulitis Abscess Duration 0-3 days 1-5 days 4-10 days Pain,borders mild,diffuse severe,diffuse localized Size variable large small Color normal red shiny center Consistency jellylike boardlike soft center Progression increasing increasing decreasing Pus absent absent present Seriousness low greater less Comparison of Edema, Cellulitis, and Abscess Laboratory diagnosis blood Rt, CRP, bacterial culture, antibiotic susceptibility testing Needle aspiration, ultrasonic, CT deeper abscess X-ray, CT, 3D-CT osteomylitis other examination Treatment The treatment of infection must be aimed at restoring the original balance. It is important to fully appreciate the concept that the host is primarily responsible for curing the infection. Surgical and antibiotic therapy are merely aids to help the patient. Local therapy keep local cleanliness, avoid stimulation and movement, herb dressing Surgery incision and drainage, eliminate causative factors Systemic therapy antibiotics therapy, supporting therapy Principle 1: Determine severity of infection complete history symptoms physical examination respiratory obstruction ! Principle 2: Evaluate patients host defense situation medical conditions that compromise host defense uncontrolled metablolic diseases systemic disease AIDS pregnancy Principle 3: Treat infection surgically drain the abscess (if present) remove bacteria relieve tissue tension antimicrobial therapy (if necessary) Objective vent abscess or putrescence release of pain and tension causing by swelling prevent the occurrence of complication incision and drainage Indication pain aggravation, obvious swell, palpation to fluctuance, pain palpation point, pus extract by aspiration antibiotic-uncontrolled infection, obvious systemic toxicosis multispace infection, dyspnea, swallow difficulty tuberculosis of lymphonodus, inefficacy to anti-tubercolosis treatment and abscess formation incision and drainage Guidelines for successful incision and drainage Local anesthesia Guidelines for successful incision and drainage hide the Incisions Guidelines for successful incision and drainage make all incisions through skin or mucosa into connective tissue Guidelines for successful incision and drainage use a blunt hemostat to open and explore any compartments within the abscess pocket Establish drainage，the insertion of drain made from rubber dam material or iodoform gauze should permit continuous drainage and provide adequate analgesia. Patients with a drain in place should be examined daily, replacing for every 24-48 h. Irrigate the drain daily with normal saline or an antibiotic solution. Principle 4: Support patient medically Patient care is importantDehydration alone can account for an increase in temperature Adequate nourishment is essential，in liquid or soft form if necessary A laxative can be suggested if neededComplete rest is necessary. Analgesics and sedatives will relieve pain and anxiety Principle 5: Choose appropriate antibiotic Mechanism inhibit the synthesize of cellular wall of bacteria Injury the cytoplasmic membrane Inhibit the synthesize of protein Inhibit the metabolism of nucleic acid Principle 6: Evaluate patients response A variety of situations can cause failure of treatment Failure to drain abscess Depressed host defenses Presence of a foreign body Failure of antibiotic to reach bacteria, osteomyelitis Inadequate antibiotic dose Wrong bacteriologic diagnosis and antibiotic selection Penicillin group (青霉素类） low toxicity for action against bacterial cell wall that mammalian tissue does not have inexpensive classic antimicrobial spectrum : streptococcus, staphylococcus, many anaerobes, neisseria, treponema( 螺旋体). drug allergy The variety antibiotic available Cephalosporin group （头孢类） broad-spectrum antibiotics, bactericidal, against both gram-positive and gram-negative initial treatment of infection where the specific organism is unknown first generation, effective to gram-positive second and third generation, enhanced antibacterial activity Clindamycin （克林霉素） bacteriostatic antibactetial spectrum including streptococcus, staphylococcus and anaerobic Metronidazole (甲硝唑） occasionally an old drug finds a new use treatment for trichomonas bactericidal for obligate anaerobes, peptococcus adverse reaction disulfiram, cause severe abdominal cramping, nausea, vomiting allergy side effects are those expected problems that arise in many patients who taking normal doses of the drug for short periods of time Toxicity reactions are those that usually occur as a result of excessive dose or duration of therapy but can occur in individual patients at normal doses The most common toxicities are neural, renal, hepatic, and hematological injury Adverse reactions of antibiotics Narrow-spectrum fewest adverse reactions well-established but still effective antibiotic Bactericidal rather than bacteriostatic less expensive Choice of antibiotics The principle of therapeutic antibiotic application clearly established bacterial infection laboratory culture and antibiotic susceptibility studies indication of combination treatment: life-treatening infection， susceptibility tested not obtained , mix infection, long-term therapy Administer antibiotic properly: dose, dose interval, duration of therapy, route of delivery The principle of therapeutic antibiotic application Principle of prophylactic antibiotics use the length of the surgery compromised host, poorly controlled metabolic disease, the olderly chemotherapeutic immunosuppressive or glucocorticoid drug implatation Prevention of wound infection Class , incision Class incision with high risk of infection Fast facts on inflammation Inflammation is the bodys attempt at self-protection to remove harmful stim