SURGICAL INFECTION 医疗7年制.ppt

SURGICALINFECTION,ByDr.ShiChengProfessorofSurgeryDepartmentofGeneralSurgeryBeijingTiantanHospitalCapitalMedicalUniversity,Contents,IntroductionClassificationInflammationandsystemicsurgicalinfectionSepsisFungalinfectionTetanusTheappropriateapplicationofantibiotics,Introduction,ClassificationSpecificandNonspecificinfection:invasivemicro-organismsSpecificinfection:includingtuberculosis,tentanus,gasgangrene,etal.Nonspecificinfection:pyogenicAcute,subacuteandchronic:duration.(twomonths)Externalinfectionandinternalinfection:invasivewayOpportunisticinfection,superinfection,nosocomialinfection:conditions,Inflammationandsystemicsurgicalinfection,SYSTEMICINFLAMMATORYRESPONSESYNDROME(SIRS),Patientpresentswithtwoormoreofthefollowingcriteria.1.temperature38Cor90beats/minute3.respiration20/minorPaCO212,000/mm3,10%immature(band)cells,Etiology,Infectionfactor:thecommoncause,Sepsis.Noninfectionfactor:severetrauma,burn,pancreatitis,shock,ischemia-reperfusioninjury.,Pathophysiology,LocalinflammationSystemicinflammationTheroleofinflammationmediatorinSIRSRegulationandoutofcontroloftheinflammationresponse,SIRS,Sepsis,Theconcepts,SepsisThesystemicinflammatoryresponsetoinfection.SepsissyndromeSepsis(SIRS)associatedwithorgandysfunction,hypoperfusion,orhypotension.Hypoperfusionandperfusionabnormalitiesmayinclude,butarenotlimitedto,lacticacidosis,oliguria,oranacutealterationinmentalstatus.Bacteremia.Thepresenceofviablebacteriaincirculatingblood.,SystemicFactorscontributingtotheincreasingincidenceofsepsis,1.Miscellaneousconditions:childbirth,septicabortion,traumaandwidespreadburns,intestinalulceration.2.widespreaduseofcorticosteroidandimmunosuppressivetherapiesfororgantransplantsandinflammatorydiseases3.longerlivesofpatientspredisposedtosepsis,cirrhosisofliver,diabetics,malnutrition,anemia,cancerpatients,neutropenia,leukemia,dysproteinemias,patientswithmajororganfailure,andwithgranulocytopenia.4.Neonatesandtheelderlyaremorelikelytodevelopsepsis(ex.groupBStreptococcalinfections).5.aggressiveoncologicalchemotherapyandradiationtherapy6.AIDS,localconditionsatincreasedrisksofdevelopingsepsis,1.Openingtrauma,burning,perforationofgastrointestine,surgery,puncture2.increaseduseofinvasivedevicessuchassurgicalprotheses,inhalationequipment,andintravenousandurinarycatheters.3.Intraductalobstruction4.Foreignbodyornecrotictissue.5.Bloodobstacleoflocaltissue,Etiology,Gram-negativebacteria.Escherichiacoli,Klebsiellapneumoniae,Pseudomonasaeruginosa,Proteusspp.,Serratiaspp.,Neisseriameningitidis.Gram-positivebacteria.Staphylococcusaureus,coagulase-negativeStaphylococcus,Streptococcuspneumoniae,Streptococcuspyogenes,enterococci.Othercauses.Opportunisticfungi(2%to3%),viral,rickettsia,andprotozoa,OutcomeofInfecion,ResolutionAbscessFormationDiffusionChronicinflammation,ClinicalManifestations,PrimaryinfectionfocusSystemicinflammationresponseHypoperfusionabnormalitiesoforgans.,Systemicinflammationresponse,Fever,chills.Theymaybeabsentinseriousinfections,especiallyinelderlyindividuals.WBC,leukocytosiswithleftshiftTachycardia,tachypneaTachypneaaccompaniedwithmildrespiratoryalkalosisandalterationinmentalstatusmaybetheonlysignoftheelder.,Hypoperfusionabnormalitiesoforgans,lacticacidosis,oliguria,Tachypnea,hypoxia,Pao2Anacutealterationinmentalstatus.Hyperbilirubinemia,thrombocytopenia,Septicshock,organfailure,PhysicalExamination,MildenlargementofliverorspleenSkineruption(reddishpatches)Metastaticabscess,Diagnosis,DiseaseEvidenceBacteremiaPositivebloodcultureSepsisTheevidenceofinfectionthemanifestationofSIRSSepsissyndromePositivebloodculturetheevidenceofsepsisHypoperfusionoforganshypoxemia,oliguria,alterationinmentalstatus,Diagnosis,Gram-positivebacteriasepsisGram-negativebacteriasepsisCandidaalbicanssepsisAnaerobicbacteriasepsis,Differentsepsisclinicalcharacters,SepsiscommonpathogenicfeverchillshockrashdiseasebacteriametastaticabscessG+CarbuncleStaphylococcuscontinued(-)warm(+)CellulitisaureusremittentlatepyogenicinfectionofboneandjointG-biliary,urinaryEscherichiaintermittent(+)cold(-)intestinalinfectioncoliearlyseriousburnCandidaafterapplyingCandidas(+)(+)(+)(-)albicansbroad-spectrumalbicanantibioticsAnaerobicseriousinfectionBacteroidesbacteriaabdominalandfragilis(+)(+)(+)metastaticabscesspelviccavity,Therapy,TheoriginalfocusofinfectionmustbetreatedsurgicaldrainagemaybeneededinsomecasesTheapplicationofantibioticsPatientswithseveresepsisshouldbeinICU.SupporttherapyInhibitionorblockadeofinflammationmediatorMonoclonalantibodiesagainstgram-negativeendotoxin,steroids,andanti-TNFantibodieshavenotdemonstratedsignificantreduction.Recentstudysuggestslow-dosesteroidsmayhelpinsepticshock,butthisisnotyetstandardofcare.,Introduction,Surgicalfungalinfectionisanopportunisticinfection.Thedeeperinfectionisthemajor.MostsurgicalfungalinfectionsareinfactduetoCandida,butAspergillusinfectionsarealsoseen.,Pathogenesis,C.albicansisanasexual,diploid,dimorphicfungusthatiswidespreadonhumansandintheirenvironment.Westilldontunderstandwhythiscommoncommensalsometimesbecomespathogenic,althoughimpairedhostdefencemechanismsseemcrucial.,Riskfactorsforopportunisticfungalinfections,1.Neutropaenicpatientsfollowingchemotherapy,andotheroncologypatientswithimmunesuppression;2.PersonsimmunecompromisedduetoAcquiredImmuneDeficiencySyndromecausedbyHIVinfection;3.Patientsinintensivecare(ICU),whoarenotnecessarilyneutropaenic,butarecompromisedduetothepresenceoflong-termintravascularlinesorotherbreachesintheirintegument,severesystemicillnessorburns,andprolongedbroad-spectrumantibiotictherapy.,Other(quoted)predisposingfactors,APACHEscore10;renaldysfunction;haemodialysis;surgeryforacutepancreatitis,orevenpossiblysplenectomy;recurentGITperforation;Hickmanncatheters.,Clinicalmanifestations,C.albicanscausedigestivetract,respiratorytractandurinarytractinfection.BlooddisseminatedcandidiasisAspergilluscausepneumonia.,Diagnosis,Ifyoudontsuspectit,youllmissit!Conventionaldiagnosisoftheseinfections,basedonbloodculturesorcultureoftheoffendingorganismfrommultiplesites.Newerteststhathavebeenadvocatedforearlydiagnosisofsystemicfungalinfectioninclude:SandwichELISAforcirculatinggalactomannanPCRshowspromiseinthediagnosisofCandidainfections,evenunusualspecies.,Treatment,Therapytoetiology.Antifungaltherapy.AmphotericinB0.5-1mg/kg.divFluconazoleandotherAzoles400mg/firstday,200-400mg/d,Prevention,AppropriateapplyingantibioticsProphylacticapplyingantifungaldrugs,Whatistetanus?,Tetanusisanacute,sometimesfatal,diseaseofthecentralnervoussystem,causedbythetoxinofthetetanusbacterium,whichusuallyentersthebodythroughanopenwound.,Pathogenesis,TetanusresultsfrominfectionwithCtetani,amobile,spore-forming,anaerobic,gram-positivebacillus.Thisbacillusisfoundinoronsoil,manure,dust,clothing,skin,and10-25%ofhumanGItracts.Thesporesneedtissuewiththeproperanaerobicconditionstogerminate;theidealmediumiswoundswithtissuenecrosis.,Pathogenesis,ThesporesofCtetanigerminateandproduce2toxins:tetanolysinandtetanospasmin.Theactionofthelatterhelpsexplaintheclinicalmanifestationsofthedisease.,Pathogenesis,Tetanospasminissynthesizedasasingle151-kdchainandiscleavedtogeneratetoxinswith2chainsjoinedbyasingledisulfidebond.Theheavychain(100kd)isresponsibleforspecificbindingtoneuronalcellsandforproteintransport.Thelightchain(50kd)blocksthereleaseofneurotransmitters.,Pathogenesis,Oncethetoxinissynthesized,itmovesfromthecontaminatedsitetothespinalcordin2-14days.Whenthetoxinreachesthespinalcord,localizedorcephalictetanusmayoccurinitially,followedbygeneralizedtetanus.,ClinicalManifestation,IncubationTheincubationperiodfortetanusisusually2to14days,withmostsymptomsbeginningaroundthe7-8day,butonsetmayrangefrom24hoursto3weeks.,ClinicalManifestation,Tetanusoftenbeginswithmusclespasmsinthejaw(calledtrismus),accompaniedbydifficultyswallowingandstiffnessorpaininthemusclesoftheneck,shoulders,orback.Thesespasmscanspreadtothemusclesoftheabdomen,upperarms,andthighs.,Symptoms,stiffnessofjaw(alsocalledlockjaw)difficultyswallowingcontractionoffacialmusclesstiffnessofabdominalandbackmusclesSweatingpainfulmusclespasmsnearthewoundarea(iftheseaffectthelarynxorchestwall,theymaycauseasphyxiation),Physical,Commonfirstsignsoftetanusareheadacheandmuscularstiffnessinthejaw(ie,lockjaw),followedbyneckstiffness,difficultyswallowing,rigidityofabdominalmuscles,spasms,andsweating.Severetetanusresultsinopisthotonos,flexionofthearms,extensionofthelegs,periodsofapnearesultingfromspasmoftheintercostalmusclesanddiaphragm,andrigidityoftheabdominalwall.Lateinthedisease,autonomicdysfunctiondevelops,withhypertensionandtachycardiaalternatingwithhypotensionandbradycardia.,Complications,Themostcommoncomplicationisspasmofthevocalcordsand/orspasmsoftherespiratorymusclesthatcauseinterferencewithbreathing.Asphyxiation,pneumoniaOthercomplicationsincludemuscleavulsion,fractures,dislocationstachycardia,andheartfailure.,DIFFERENTIALS,RabiesEncephalitisStrychninepoisoningOtherProblemstobeConsidered:DentalinfectionsLocalinfectionsHysteria,Prevention,Therearetwoimportantcomponentsoftetanusprevention:tetanusimmunization(receivingroutinetetanusvaccinations)andwhatsknownaspost-exposuretetanusprophylaxis(receivingashotafteraninjuryoccurs).,Prevention,Forchildren,tetanusimmunizationispartoftheDTaP(diphtheria,tetanus,andacellularpertussis)vaccinations.ActiveimmunizationPost-exposuretetanusprophylaxisalsoinvolvesgettingtetanusshots,butafteraninjuryoccurs.Passiveimmunization,Treatment,ThoroughcleaningofthewoundNeutronlizethefreetoxinPassiveimmunizationwithhumantetanusimmuneglobulin(TIG)shortensthecourseoftetanusandmaylessenitsseverity.Adoseof500Uappearsaseffectiveaslargerdoses.OrTAT20000-50000UIV,Treatment,TocontrolspasmsDiazepamiv,10mgtid.Luminal0.1im.Physiciansalsousesedativehypnotics,narcotics,inhalationalanesthetics,neuromuscularblockingagents,andcentrallyactingmusclerelaxants(eg,intrathecalbaclofen).,Treatment,Securinganadequateairway.Atracheotomyinseverecases(withrespiratoryproblems)AntibioticsMetronidazole(eg,0.5gq6h)hascomparableorbetterantimicrobialactivity,andpenicillinisaknownantagonistofGABA,asistetanustoxin.,Treatment,SupportivetherapyParenteralnutritionIntensivenursing,Theappropriateapplicationofantibiotics,Background,Theglobalincreaseinresistancetoantimicrobialdrugs,includingtheemergenceofbacterialstrainsthatareresistanttoallavailableantibacterialagents,hascreatedapublichealthproblemofpotentiallycrisisproportions.,Theroleofantibiotics,InhibitscellwallsynthesisImpairmentofbacterialDNAsynthesisDisruptionofmembranebarrierfunctionDisruptionofribosomalproteinsynthesis,ThecommonusedAntibiotics,A.AmphotericinBB.PenicillinC.CephalosporinsD.-lactamase:ImipenemE.AminoglycosidesF.QuinolonesG.ClindamycinH.Antianaerobic-microbacterialdrugs,*Prophylacticuseofantibioticsperioperativeperiod,Indication(1)Severetrauma,severeburn,Anywoundwithknowngrossbacterialcontamination(2)Operationsenteringthegastrointestinaltract,respiratorytract,femalegenitaltractandbowelpreparationbeforecolonsurgery(3)Implantationofanypermanentprostheticmaterial(4)Highriskfactorofinfection:Diabetesmellitus,elder,malnutrition,granulocytopenia,Steroids,Immunosuppression,oncologicalchemotherapyetal.(5)Cardiacvalvulardiseaseorvalvesurgery,organtransplantation,Craniotomy,*Administrationofprophylacticantibiotics,ChoiceofantibioticsTimingofadministrationDosageselectionDurationofprophylaxisRouteofadministration,GuidelinesforUse,ChoiceofantibioticsTheantibioticsselectedforprophylaxismustcovertheexpectedpathogensforthatoperativesite.CephalosporinRecommeded:Cefuroxime(2ndgenerationcephalosporin),GuidelinesforUse,Timingofadministration