SURGICALINFECTION医疗专题知识专家讲座

SURGICALINFECTIONByDr.ShiChengProfessorofSurgeryDepartmentofGeneralSurgeryBeijingTiantanHospitalCapitalMedicalUniversity第1页ContentsIntroductionClassificationInflammationandsystemicsurgicalinfectionSepsisFungalinfectionTetanusTheappropriateapplicationofantibiotics第2页IntroductionClassificationSpecificandNonspecificinfection:invasivemicro-organismsSpecificinfection:includingtuberculosis,tentanus,gasgangrene,etal.Nonspecificinfection:pyogenicAcute,subacuteandchronic:duration.(<threeweeksor>twomonths)Externalinfectionandinternalinfection:invasivewayOpportunisticinfection,superinfection,nosocomialinfection:conditions第3页Inflammationandsystemicsurgicalinfection第4页SYSTEMICINFLAMMATORY

RESPONSESYNDROME(SIRS)

Patientpresentswithtwoormoreofthefollowingcriteria.1.temperature>38°Cor<36°C2.heartrate>90beats/minute3.respiration>20/minorPaCO2<32mmHg4.leukocytecount>12,000/mm3,<4,000/mm3or>10%immature(band)cells第5页EtiologyInfectionfactor:thecommoncause,Sepsis.Noninfectionfactor:severetrauma,burn,pancreatitis,shock,ischemia-reperfusioninjury.第6页PathophysiologyLocalinflammationSystemicinflammationTheroleofinflammationmediatorinSIRSRegulationandoutofcontroloftheinflammationresponse第7页SIRS第8页Sepsis第9页TheconceptsSepsisThesystemicinflammatoryresponsetoinfection.SepsissyndromeSepsis(SIRS)associatedwithorgandysfunction,hypoperfusion,orhypotension.Hypoperfusionandperfusionabnormalitiesmayinclude,butarenotlimitedto,lacticacidosis,oliguria,oranacutealterationinmentalstatus.Bacteremia.Thepresenceofviablebacteriaincirculatingblood.第10页

Systemic

Factorscontributingtotheincreasingincidenceofsepsis1.Miscellaneousconditions:childbirth,septicabortion,traumaandwidespreadburns,intestinalulceration.

2.widespreaduseofcorticosteroidandimmunosuppressivetherapiesfororgantransplantsandinflammatorydiseases

3.longerlivesofpatientspredisposedtosepsis,cirrhosisofliver,diabetics,malnutrition,anemia,cancerpatients,neutropenia,leukemia,dysproteinemias,patientswithmajororganfailure,andwithgranulocytopenia.4.Neonatesandtheelderlyaremorelikelytodevelopsepsis(ex.groupBStreptococcalinfections).5.aggressiveoncologicalchemotherapyandradiationtherapy6.AIDS,第11页localconditionsatincreasedrisksofdevelopingsepsis1.Openingtrauma,burning,perforationofgastrointestine,surgery,puncture2.increaseduseofinvasivedevicessuchassurgicalprotheses,inhalationequipment,andintravenousandurinarycatheters.3.Intraductalobstruction4.Foreignbodyornecrotictissue.5.Bloodobstacleoflocaltissue第12页EtiologyGram-negativebacteria.Escherichiacoli,Klebsiellapneumoniae,Pseudomonasaeruginosa,Proteusspp.,Serratiaspp.,Neisseriameningitidis.Gram-positivebacteria.

Staphylococcusaureus,coagulase-negativeStaphylococcus,Streptococcuspneumoniae,Streptococcuspyogenes,enterococci.Othercauses.Opportunisticfungi(2%to3%),viral,rickettsia,andprotozoa第13页第14页OutcomeofInfecionResolution

AbscessFormation

DiffusionChronicinflammation

第15页ClinicalManifestationsPrimaryinfectionfocusSystemicinflammationresponseHypoperfusionabnormalitiesoforgans.第16页SystemicinflammationresponseFever,chills.Theymaybeabsentinseriousinfections,especiallyinelderlyindividuals.WBC,leukocytosiswithleftshiftTachycardia,tachypneaTachypneaaccompaniedwithmildrespiratoryalkalosisandalterationinmentalstatusmaybetheonlysignoftheelder.第17页Hypoperfusionabnormalitiesoforganslacticacidosis,oliguria,Tachypnea,hypoxia,Pao2Anacutealterationinmentalstatus.Hyperbilirubinemia,thrombocytopenia,Septicshock,organfailure

第18页PhysicalExaminationMildenlargementofliverorspleenSkineruption(reddishpatches)Metastaticabscess第19页

Diagnosis

DiseaseEvidence

BacteremiaPositivebloodcultureSepsisTheevidenceofinfectionthemanifestationofSIRS

Sepsissyndrome

PositivebloodculturetheevidenceofsepsisHypoperfusionoforganshypoxemia,oliguria,alterationinmentalstatus第20页DiagnosisGram-positivebacteriasepsisGram-negativebacteriasepsisCandidaalbicanssepsisAnaerobicbacteriasepsis第21页Differentsepsisclinicalcharacters

SepsiscommonpathogenicfeverchillshockrashdiseasebacteriametastaticabscessG+Carbuncle

Staphylococcus

continued

(-)warm(+)

Cellulitis

aureus

remittent

late

pyogenicinfectionofboneandjoint

G-biliary,urinary

Escherichiaintermittent(+)cold

(-)

intestinalinfectioncoli

early

seriousburn

Candida

afterapplyingCandidas

(+)

(+)(+)(-)

albicans

broad-spectrumalbicanantibioticsAnaerobic

seriousinfection

Bacteroidesbacteria

abdominalandfragilis

(+)

(+)(+)metastaticabscess

pelvic

cavity

第22页TherapyTheoriginalfocusofinfectionmustbetreated

surgicaldrainagemaybeneededinsomecases

TheapplicationofantibioticsPatientswithseveresepsisshouldbeinICU.SupporttherapyInhibitionorblockadeofinflammationmediator

Monoclonalantibodiesagainstgram-negativeendotoxin,steroids,andanti-TNFantibodieshavenotdemonstratedsignificantreduction.Recentstudysuggestslow-dosesteroidsmayhelpinsepticshock,butthisisnotyetstandardofcare.第23页第24页第25页Introduction

Surgicalfungalinfectionisanopportunisticinfection.Thedeeperinfectionisthemajor.MostsurgicalfungalinfectionsareinfactduetoCandida,butAspergillusinfectionsarealsoseen.第26页PathogenesisC.albicansisanasexual,diploid,dimorphicfungusthatiswidespreadonhumansandintheirenvironment.Westilldon'tunderstandwhythiscommoncommensalsometimesbecomespathogenic,althoughimpairedhostdefencemechanismsseemcrucial.第27页Riskfactorsforopportunisticfungalinfections1.Neutropaenicpatientsfollowingchemotherapy,andotheroncologypatientswithimmunesuppression;2.PersonsimmunecompromisedduetoAcquiredImmuneDeficiencySyndromecausedbyHIVinfection;3.Patientsinintensivecare(ICU),whoarenotnecessarilyneutropaenic,butarecompromisedduetothepresenceoflong-termintravascularlinesorotherbreachesintheirintegument,severesystemicillnessorburns,andprolongedbroad-spectrumantibiotictherapy.

第28页Other(quoted)predisposingfactorsAPACHEscore>10;renaldysfunction;haemodialysis;surgeryforacutepancreatitis,orevenpossiblysplenectomy;recurentGITperforation;Hickmanncatheters.第29页ClinicalmanifestationsC.albicanscausedigestivetract,respiratorytractandurinarytractinfection.BlooddisseminatedcandidiasisAspergilluscausepneumonia.第30页DiagnosisIfyoudon'tsuspectit,you'llmissit!

Conventionaldiagnosisoftheseinfections,basedonbloodculturesorcultureoftheoffendingorganismfrommultiplesites.

Newerteststhathavebeenadvocatedforearlydiagnosisofsystemicfungalinfectioninclude:SandwichELISAforcirculatinggalactomannanPCRshowspromiseinthediagnosisofCandidainfections,evenunusualspecies.第31页TreatmentTherapytoetiology.Antifungaltherapy.

AmphotericinB0.5-1mg/kg.divFluconazoleandotherAzoles400mg/firstday,200-400mg/d第32页PreventionAppropriateapplyingantibioticsProphylacticapplyingantifungaldrugs第33页第34页Whatistetanus?Tetanusisanacute,sometimesfatal,diseaseofthecentralnervoussystem,causedbythetoxinofthetetanusbacterium,whichusuallyentersthebodythroughanopenwound.第35页PathogenesisTetanusresultsfrominfectionwithCtetani,amobile,spore-forming,anaerobic,

gram-positivebacillus.Thisbacillusisfoundinoronsoil,manure,dust,clothing,skin,and10-25%ofhumanGItracts.Thesporesneedtissuewiththeproperanaerobicconditionstogerminate;theidealmediumiswoundswithtissuenecrosis.

第36页PathogenesisThesporesofCtetanigerminateandproduce2toxins:tetanolysinandtetanospasmin.Theactionofthelatterhelpsexplaintheclinicalmanifestationsofthedisease.第37页PathogenesisTetanospasminissynthesizedasasingle151-kdchainandiscleavedtogeneratetoxinswith2chainsjoinedbyasingledisulfidebond.Theheavychain(100kd)isresponsibleforspecificbindingtoneuronalcellsandforproteintransport.Thelightchain(50kd)blocksthereleaseofneurotransmitters.

第38页PathogenesisOncethetoxinissynthesized,itmovesfromthecontaminatedsitetothespinalcordin2-14days.Whenthetoxinreachesthespinalcord,localizedorcephalictetanusmayoccurinitially,followedbygeneralizedtetanus.第39页ClinicalManifestationIncubation

Theincubationperiodfortetanusisusually2to14days,withmostsymptomsbeginningaroundthe7-8day,butonsetmayrangefrom24hoursto3weeks.第40页ClinicalManifestationTetanusoftenbeginswithmusclespasmsinthejaw(calledtrismus),accompaniedbydifficultyswallowingandstiffnessorpaininthemusclesoftheneck,shoulders,orback.Thesespasmscanspreadtothemusclesoftheabdomen,upperarms,andthighs.第41页Symptomsstiffnessofjaw(alsocalledlockjaw)difficultyswallowingcontractionoffacialmusclesstiffnessofabdominalandbackmusclesSweatingpainfulmusclespasmsnearthewoundarea(iftheseaffectthelarynxorchestwall,theymaycauseasphyxiation)

第42页PhysicalCommonfirstsignsoftetanusareheadacheandmuscularstiffnessinthejaw(ie,lockjaw),followedbyneckstiffness,difficultyswallowing,rigidityofabdominalmuscles,spasms,andsweating.Severetetanusresultsinopisthotonos,flexionofthearms,extensionofthelegs,periodsofapnearesultingfromspasmoftheintercostalmusclesanddiaphragm,andrigidityoftheabdominalwall.Lateinthedisease,autonomicdysfunctiondevelops,withhypertensionandtachycardiaalternatingwithhypotensionandbradycardia.第43页第44页第45页第46页

Complications

Themostcommoncomplicationisspasmofthevocalcordsand/orspasmsoftherespiratorymusclesthatcauseinterferencewithbreathing.Asphyxiation,pneumoniaOthercomplicationsincludemuscleavulsion,fractures,dislocationstachycardia,andheartfailure.第47页DIFFERENTIALS

RabiesEncephalitisStrychninepoisoning

OtherProblemstobeConsidered:

Dentalinfections

Localinfections

Hysteria

第48页

Prevention

Therearetwoimportantcomponentsoftetanusprevention:tetanusimmunization(receivingroutinetetanusvaccinations)andwhat'sknownaspost-exposuretetanusprophylaxis(receivingashotafteraninjuryoccurs).第49页

Prevention

Forchildren,tetanusimmunizationispartoftheDTaP(diphtheria,tetanus,andacellularpertussis)vaccinations.

ActiveimmunizationPost-exposuretetanusprophylaxisalsoinvolvesgettingtetanusshots,butafteraninjuryoccurs.

Passiveimmunization第50页TreatmentThoroughcleaningofthewound

Neutronlizethefreetoxin

Passiveimmunizationwithhumantetanusimmuneglobulin(TIG)shortensthecourseoftetanusandmaylessenitsseverity.Adoseof500Uappearsaseffectiveaslargerdoses.OrTAT20230-50000UIV第51页

TreatmentTocontrolspasms

Diazepamiv,10mgtid.Luminal0.1im.Physiciansalsousesedativehypnotics,narcotics,inhalationalanesthetics,neuromuscularblockingagents,andcentrallyactingmusclerelaxants(eg,intrathecalbaclofen).第52页TreatmentSecuringanadequateairway.Atracheotomyinseverecases(withrespiratoryproblems)Antibiotics

Metronidazole(eg,0.5gq6h)hascomparableorbetterantimicrobialactivity,andpenicillinisaknownantagonistofGABA,asistetanustoxin.第53页TreatmentSupportivetherapy

ParenteralnutritionIntensivenursing第54页Theappropriateapplicationofantibiotics第55页BackgroundTheglobalincreaseinresistancetoantimicrobialdrugs,includingtheemergenceofbacterialstrainsthatareresistanttoallavailableantibacterialagents,hascreatedapublichealthproblemofpotentiallycrisisproportions.第56页TheroleofantibioticsInhibitscellwallsynthesisImpairmentofbacterialDNAsynthesisDisruptionofmembranebarrierfunctionDisruptionofribosomalproteinsynthesis第57页ThecommonusedAntibioticsA.AmphotericinBB.PenicillinC.CephalosporinsD.β-lactamase:ImipenemE.AminoglycosidesF.QuinolonesG.ClindamycinH.Antianaerobic-microbacterialdrugs第58页*

ProphylacticuseofantibioticsperioperativeperiodIndication(1)Severetrauma,severeburn,Anywoundwithknowngrossbacterialcontamination(2)Operationsenteringthegastrointestinaltract,respiratorytract,femalegenitaltractandbowelpreparationbeforecolonsurgery(3)Implantationofanypermanentprostheticmaterial(4)Highriskfactorofinfection:Diabetesmellitus,elder,malnutrition,granulocytopenia,Steroids,Immunosuppression,oncologicalchemotherapyetal.(5)Cardiacvalvulardiseaseorvalvesurgery,organtransplantation,Craniotomy

第59页*AdministrationofprophylacticantibioticsChoiceofantibioticsTimingofadministrationDosageselectionDurationofprophylaxisRouteofadministration第60页GuidelinesforUseChoiceofantibiotics

Theantibioticsselectedforprophylaxismustcovertheexpectedpathogensforthatoperativesite.Cephalosporin

Recommeded:

Cefuroxime(2ndgenerationcephalosporin)第61页GuidelinesforUseTimingofadministration

Givesingledoseinjection0-2hourspreoperation

ideallywithin30minutesoftheinductionofanaesthesiaDosageselection

Asinglestandardtherapeuticdoseofantibioticissufficientforprophylax