Transcript ACUTE SURGICAL INFECTION

ACUTE SURGICAL
INFECTION
Non-Specific Acute Infection
Specific Acute
Infection
Non-Specific Acute
Infection
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Postoperative Wound Infection
Cellulitis
Erysipelas
Boil (Furuncle)
Carbuncle
Hydradenitis Suppurativa
Acute Abscess
Acute Lymphangitis and
Lymphadenitis
Bacteraemia and Septicaemia
Specific Acute Infections
Tetanus
 Gas Gangrene
 Necrotizing Fasciitis
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Postoperative Wound
Infections
Are caused by the presence of
contaminating microbes derived from :
Endogenous
OR
Exogenous
Postoperative Wound
Infection
Predisposing Factors:
# General
1- Poor general condition
2- Systemic disease
3- Drugs that cause immunosuppression
Postoperative Wound
Infection
# Local :
1- Poor blood supply
2- Poor surgical technique
3- Presence of foreign bodies
4- Nature of the operation
5- Defect in sterilization technique in
the operating theatre
Types of surgical wounds
Operative wounds are divided into three
categories :
1- Clean The risk of infection is 1-2%
2- Clean contaminated The risk of
infection 2-5%
3- Contaminated The risk of infection
is 5-30%
Pathology
Acute inflammatory stage with local
vasodilatation and infiltration by
polymorph nuclear leucocytes.
This is followed by suppuration with
purulent discharge
Clinical Picture
Wound infection usually appears
between the fifth and tenth days
postoperative
* Fever * Pain in the wound
Signs:
_ swollen
_tenderness
_redness
_fluctuant
Differential Diagnosis
Other causes of postoperative fever
- chest infection
- DVT
- UTI
Other causes of wound swelling
- heamatoma
Prophylaxis
* Improve the defense mechanism
* Control the predisposing factors
* Prophylactic antibiotics
* In bowel surgery, mechanical and
chemical preparation of the bowel
* Meticulous surgery
* Operation in septic areas with
heavily contaminated wounds should
be left open
Treatment
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Surgical drainage of the pus
Antibiotics in invasive infections
Look for hospital acquired infection
Cellulitis
Is an invasive non suppurative
infection of the loose connective
tissue
 Organism :
 streptococci [common]
 staphylococci [occasionally]
 mix
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Clinical picture
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The affected area is red,indurated,hot
and painful
It spreads rapidly with ill defined edge
The skin may be the seat of blisters
Fever
Lymphangitis in the form of red streaks
No suppuration
In severe cases patches of skin necrosis
with sloughing of subcutaneous tissues
Differetial Diagnosis
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Contact allergy
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Chemical inflammation
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DVT
Treatment
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Rest and elevation of the affected part
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Antibiotic penicillin iv
Erysipelas
Is a rapidly spreading non-suppurative
inflammation of the lymphatics of the
skin caused by a specific strain of
hemolytic streptococci
Clinical Picture
Toxemia
 Locally : similar to cellulitis,but there
are the following differences:
1. The color of the skin is rose-pink
2. The edge is well defined
3. There may islets of inflammation
beyond the spreading margin
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Complications
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1. Facial erysipelas may lead to
cavernous sinus thrombosis
2. Septicemia
3. Recurrent erysipelas may block the
lymphatics leading to elephantiasis.
Treatment
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Isolation
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Similar to cellulitis
Boil [Furuncle]
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Is a staphylococcal infection of a hair
follicle or a sebaceous gland.
The common sites:
face, neck and axilla.
Common in diabetics.
Clinical Picture
A small painful indurated swelling which
is
- red
- hot
- and very tender
Treatment
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1.Antibiotics.
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2.Antiseptic.
Carbuncle
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Is infective gangrene of the
subcutaneous tissues usually
secondary to infection by
Staphylococcus aureus.
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It is common in immunocompromised
patients as in diabetics.
The common sites:
face, nape of the neck, and the back
Pathology
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Infection usually starts in a hair follicle
Extends to the subcutaneous fat
where other hair follicles get the
infection.
Multiple areas of necrosis and
thrombosis of blood vessels occur.
Patches of skin undergo sloughing
and separate from the underlying
granulation tissue
Clinical Picture
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There is usually sever toxemia.
Starts as a painful induration of the
skin and subcutaneous tissues.
The skin is red.
Swelling its central part becomes soft.
Multiple areas of skin thin out and
separate forming multiple sinuses.
Complications
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Local spread of infection.
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Pyaemia and septicemia.
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Cavernous sinus thrombosis
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Epidural abscess or meningitis
Treatment
1.Antibiotics.
2.culture and sensitivity of the discharge.
3.control of diabetes.
4.surgical excision of sloughs.
Hydradenitis Suppurativa
Mixed staph. And streptococcal infection
of the apocrine sweat glands, in the
perineum or the axilla,produces multiple
abscesses and pus discharging sinuses.
Treatment
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Surgical drainage of abscesses.
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Antiseptic and antifungal applications.
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Surgical excision of the apocrine
sweat-bearing skin following by skin
grafting is essential.
Acute Abscess
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It is a localized suppurative
inflammation.
It is caused by pyogenic organisms.
The commonest are staphylococci that
produce a coagulase enzyme.
Pathogenesis
The organism reach the tissues by :
- direct access through wounds, scratches
and abrasions.
- local extension from an adjacent focus
- lymphatic spread.
- blood spread.
Pathology
An abscess consists of three zones:
1- A central zone of coagulative necrosis
2- An intermediate zone of granulation
tissue.
3- A peripheral zone of acute inflammation.
Sequlea
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Resolution.
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Pointing and rupture.
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Spread infection – locally
- by lymphatics or blood
Chronicity.
Clinical Picture
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Locally :- painful tender mass
-The covering skin is red, and
oedematous -The draining lymph
nodes are usually enlarged and tender
Systemic :-Fever
-Malaise
-Headache
-Tachycardia
-Anorexia
When Pus Forms
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The fever
becomes hectic.
Skin shows pitting
oedema.
The pain becomes
throbbing.
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The inflamatory
reaction becomes
localized
Fluctuation test
becomes positive.
There is shooting
leucocytosis
Treatment
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Before suppuration:
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After suppuration:
- antibiotic, rest
-hot application.
-supportive general measures.
-adequate surgical drainage.
-a specimen of the pus is sent for
culture and sensitivity.
-antibiotic if there is systemic
manifestation.
Acute Lymphangitis and
Lyphadenitis
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Acute lymphangitis:is due to infection
of lymph vessels by organisms usually
streptococci.
Acute lymphadenitis: is due to spread
of infection along lymphatics from a
septic focus in the drainage area to
the lymph- nodes.
Treatment
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Antibiotics.
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Hot applications.
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Surgical drainage if suppuration
occurs.
Bacteraemia
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Presence of bacteria which are NOT
multiplying, in the blood.
It usually follows:
- dental work.
-instrumentation of the urinary tract
It is hazardous in patients with :
-damaged heart valves.
-prosthetic valves.
-immunosuppression
Prophylactic antibiotics is essential
Septicemia
The presence of multiplying organisms
in the blood stream.
Specific Acute Infections
Tetanus
It is a specific anaerobic infection that is
mediated by neurotoxin of:
Clostridium tetani
and leads to:
nervous irritability and tetanic muscular
contractions.
Aetiology
Organism: Clostridiuam tetani is
gram positive anaerobic bacillus with a
terminal spore giving the characteristic
drum-stick appearance.
Mode Of Infection
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1. Wounds:-hypoxic,containing
devaitalized tissue or a foreign body.
2.Umbilical stump: tetanus neonatorum
Pathology
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The neurotoxin is an exotoxin produced
locally and reaches the central nervous
system along the blood stream, the
motor nerves or both.
When the toxin reaches the nervous
system, it is fixed by the motor cells and
can not be detected in the blood or CSF.
The antitoxin can only neutralize the
toxin before it gets fixed to the nervous
tissue.
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The toxin increases the exitability of
the motor cells of the medulla and
spinal cord, so slightest stimuli
produce violent spasm.
Death results from exhaustion,
hyperpyrexia, heart failure, asphyxia
or pneumonia.
Clinical Picture
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Incubation period:
- In non-immunized is short from 24H to
15 days.
- In immunized is longer than 11 days to
several weeks or months.
Symptoms during incubation period are
vague such as : tenderness, rigidity of
the muscles, swelling at the site of
wound, local twitches, restlessness, and
an anxiety.
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Tonic stage:
-Pain and tingling in the area of injury.
-Limitation of movements of the jaw.
-Spasm of the facial muscles.
-Stiffness of the neck.
-Dysphagia.
-Laryngospasm.
-Hesitancy in micturition.
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Clonic stage:
-Reflex paroxysms of violent muscular
contraction.
-Relaxation is incomplete during the
intervals between clonic contractions.
-Spasm of the intercostal muscles and
diaphragm lead to long period of
apnea. -Temperature elevated with
profuse sweating.
-Marked tachycardia
Laboratory Finding
Polymorphnuclear leucocytosis.
Prevention
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Immunization [active] with tetanus toxoid
with routine childhood immunization, with
booster injections every 7-10 years.
Individuals who previously received three or
more doses, the last within 10 years:
need a booster dose of tetanus toxoid.
Those who received less than three doses:
-need a booster dose of tetanus toxoid and
tetanus immunoglobulin [passive].
Individuals not previously immunized:
-need full immunization with tetanus toxoid
and tetanus immunoglobulin.
Treatment
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Neutralize toxin with TIG.
Wound debridment.
Avoid sudden stimuli.
Muscle relaxant with mechanical
ventilation may require tracheostomy.
Aqueous penicillin G ,10-40 million
units a day IV.
Nursing.
Gas Gangrene
It is an acute spreading infection
associated with gas formation and
profound toxaemia caused by anaerobic
spore-bearing bacilli of the clostridium
group.
Pathology
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Clostridia proliferate and produce
toxins that diffuse into the surrounding
tissue.
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The toxins destroy local circulation.
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This allows further invasion.
Factors predisposing to
gas gangrene:
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Lacerated wounds involving bulky
muscles.
Presence of foreign bodies or
devitalized tissues.
Ischemia of muscles.
Infection by anaerobic bacteria.
As a complication of above knee
amputation in patient with faecal
incontinence.
Bacteriology
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Organisms falls into two groups:
Saccharolytic organisms:
-Cl.welchii,-Cl.septicum,-and
Cl.oedematiens
Proteolytic organisms:
-Cl.sporogenes,-Cl.histolyticum and
Cl.tertium.
Clinical Picture
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The incubation period varies from few
hours to few days.
Generally ;the patient is pale, anxious,
and apprehensive.
-The temperature may be raised and
there is marked tachycardia.
-The hands are cold and clammy.
-An icteric tinge may be present and
there is oliguria.In severe case there is
shock.
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Locally: -pain and numbness in the
affected area.
-swelling and there may be crepitus
with gas bubbles.
-A sanguineous dischrge of a
characteristic odour.
-The affected muscles brick red then
greenish and finally black
discolouration,do not contract,do not
bleed if cut, the skin black.
Prevention
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Adequate debridement of wounds.
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Antibiotics.
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Avoid tissue hypoxia.
Treatment
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Wound management.
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Hyperbaric oxygenation.
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Antibiotics: penecillin.
Necrotizing Fasciitis
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It is an invasive infection usually
caused by a mixed microbial flora
including microphilic streptococci,
staphylococci, Gram-negative bacteria
and anaerobes,especially
peptostreptococci, and bacteroids.
Pathology
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The infectious process spreads along
the fascial planes and results
infectious thrombosis of the vessels
passing between the skin and deep
circulation.
Superficial skin necrosis follows.
Hemorrhagic bullae appear as the first
sign of skin death.
Fascial and subcutaneous fat necrosis
involves wider area than the skin.
Clinical Picture
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There are manifestations of toxemia
with fever and tachycardia.
The skin shows hemorrhagic bullae
and necrosis surrounded by oedema
and inflammation.
Crepitus is occasionally present.
Investigations
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Swab for culture and sensitivity
At surgery :oedematous, dull gray
fascia and subcutaneous tissue with
visible thrombi in penetrating vessels
Prevention
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Adequate debridement of wounds
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Antibiotics
Treatment
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Surgical
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Antibiotics
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Blood transfusion