SURGICALINFECTION医疗专题知识专家讲座

SURGICALINFECTIONByDr.ShiChengProfessorofSurgeryDepartmentofGeneralSurgeryBeijingTiantanHospitalCapitalMedicalUniversitySURGICALINFECTION医疗专题知识专家讲座第1页ContentsIntroductionClassificationInflammationandsystemicsurgicalinfectionSepsisFungalinfectionTetanusTheappropriateapplicationofantibioticsSURGICALINFECTION医疗专题知识专家讲座第2页IntroductionClassificationSpecificandNonspecificinfection:invasivemicro-organismsSpecificinfection:includingtuberculosis,tentanus,gasgangrene,etal.Nonspecificinfection:pyogenicAcute,subacuteandchronic:duration.(<threeweeksor>twomonths)Externalinfectionandinternalinfection:invasivewayOpportunisticinfection,superinfection,nosocomialinfection:conditionsSURGICALINFECTION医疗专题知识专家讲座第3页InflammationandsystemicsurgicalinfectionSURGICALINFECTION医疗专题知识专家讲座第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)cellsSURGICALINFECTION医疗专题知识专家讲座第5页EtiologyInfectionfactor:thecommoncause,Sepsis.Noninfectionfactor:severetrauma,burn,pancreatitis,shock,ischemia-reperfusioninjury.SURGICALINFECTION医疗专题知识专家讲座第6页PathophysiologyLocalinflammationSystemicinflammationTheroleofinflammationmediatorinSIRSRegulationandoutofcontroloftheinflammationresponseSURGICALINFECTION医疗专题知识专家讲座第7页SIRSSURGICALINFECTION医疗专题知识专家讲座第8页SepsisSURGICALINFECTION医疗专题知识专家讲座第9页TheconceptsSepsisThesystemicinflammatoryresponsetoinfection.SepsissyndromeSepsis(SIRS)associatedwithorgandysfunction,hypoperfusion,orhypotension.Hypoperfusionandperfusionabnormalitiesmayinclude,butarenotlimitedto,lacticacidosis,oliguria,oranacutealterationinmentalstatus.Bacteremia.Thepresenceofviablebacteriaincirculatingblood.SURGICALINFECTION医疗专题知识专家讲座第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,SURGICALINFECTION医疗专题知识专家讲座第11页localconditionsatincreasedrisksofdevelopingsepsis1.Openingtrauma,burning,perforationofgastrointestine,surgery,puncture2.increaseduseofinvasivedevicessuchassurgicalprotheses,inhalationequipment,andintravenousandurinarycatheters.3.Intraductalobstruction4.Foreignbodyornecrotictissue.5.BloodobstacleoflocaltissueSURGICALINFECTION医疗专题知识专家讲座第12页EtiologyGram-negativebacteria.Escherichiacoli,Klebsiellapneumoniae,Pseudomonasaeruginosa,Proteusspp.,Serratiaspp.,Neisseriameningitidis.Gram-positivebacteria.

Staphylococcusaureus,coagulase-negativeStaphylococcus,Streptococcuspneumoniae,Streptococcuspyogenes,enterococci.Othercauses.Opportunisticfungi(2%to3%),viral,rickettsia,andprotozoaSURGICALINFECTION医疗专题知识专家讲座第13页SURGICALINFECTION医疗专题知识专家讲座第14页OutcomeofInfecionResolution

AbscessFormation

DiffusionChronicinflammation

SURGICALINFECTION医疗专题知识专家讲座第15页ClinicalManifestationsPrimaryinfectionfocusSystemicinflammationresponseHypoperfusionabnormalitiesoforgans.SURGICALINFECTION医疗专题知识专家讲座第16页SystemicinflammationresponseFever,chills.Theymaybeabsentinseriousinfections,especiallyinelderlyindividuals.WBC,leukocytosiswithleftshiftTachycardia,tachypneaTachypneaaccompaniedwithmildrespiratoryalkalosisandalterationinmentalstatusmaybetheonlysignoftheelder.SURGICALINFECTION医疗专题知识专家讲座第17页Hypoperfusionabnormalitiesoforganslacticacidosis,oliguria,Tachypnea,hypoxia,Pao2Anacutealterationinmentalstatus.Hyperbilirubinemia,thrombocytopenia,Septicshock,organfailure

SURGICALINFECTION医疗专题知识专家讲座第18页PhysicalExaminationMildenlargementofliverorspleenSkineruption(reddishpatches)MetastaticabscessSURGICALINFECTION医疗专题知识专家讲座第19页

Diagnosis

DiseaseEvidence

BacteremiaPositivebloodcultureSepsisTheevidenceofinfectionthemanifestationofSIRS

Sepsissyndrome

PositivebloodculturetheevidenceofsepsisHypoperfusionoforganshypoxemia,oliguria,alterationinmentalstatusSURGICALINFECTION医疗专题知识专家讲座第20页DiagnosisGram-positivebacteriasepsisGram-negativebacteriasepsisCandidaalbicanssepsisAnaerobicbacteriasepsisSURGICALINFECTION医疗专题知识专家讲座第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

SURGICALINFECTION医疗专题知识专家讲座第22页TherapyTheoriginalfocusofinfectionmustbetreated

surgicaldrainagemaybeneededinsomecases

TheapplicationofantibioticsPatientswithseveresepsisshouldbeinICU.SupporttherapyInhibitionorblockadeofinflammationmediator

Monoclonalantibodiesagainstgram-negativeendotoxin,steroids,andanti-TNFantibodieshavenotdemonstratedsignificantreduction.Recentstudysuggestslow-dosesteroidsmayhelpinsepticshock,butthisisnotyetstandardofcare.SURGICALINFECTION医疗专题知识专家讲座第23页SURGICALINFECTION医疗专题知识专家讲座第24页SURGICALINFECTION医疗专题知识专家讲座第25页Introduction

Surgicalfungalinfectionisanopportunisticinfection.Thedeeperinfectionisthemajor.MostsurgicalfungalinfectionsareinfactduetoCandida,butAspergillusinfectionsarealsoseen.SURGICALINFECTION医疗专题知识专家讲座第26页PathogenesisC.albicansisanasexual,diploid,dimorphicfungusthatiswidespreadonhumansandintheirenvironment.Westilldon'tunderstandwhythiscommoncommensalsometimesbecomespathogenic,althoughimpairedhostdefencemechanismsseemcrucial.SURGICALINFECTION医疗专题知识专家讲座第27页Riskfactorsforopportunisticfungalinfections1.Neutropaenicpatientsfollowingchemotherapy,andotheroncologypatientswithimmunesuppression;2.PersonsimmunecompromisedduetoAcquiredImmuneDeficiencySyndromecausedbyHIVinfection;3.Patientsinintensivecare(ICU),whoarenotnecessarilyneutropaenic,butarecompromisedduetothepresenceoflong-termintravascularlinesorotherbreachesintheirintegument,severesystemicillnessorburns,andprolongedbroad-spectrumantibiotictherapy.

SURGICALINFECTION医疗专题知识专家讲座第28页Other(quoted)predisposingfactorsAPACHEscore>10;renaldysfunction;haemodialysis;surgeryforacutepancreatitis,orevenpossiblysplenectomy;recurentGITperforation;Hickmanncatheters.SURGICALINFECTION医疗专题知识专家讲座第29页ClinicalmanifestationsC.albicanscausedigestivetract,respiratorytractandurinarytractinfection.BlooddisseminatedcandidiasisAspergilluscausepneumonia.SURGICALINFECTION医疗专题知识专家讲座第30页DiagnosisIfyoudon'tsuspectit,you'llmissit!

Conventionaldiagnosisoftheseinfections,basedonbloodculturesorcultureoftheoffendingorganismfrommultiplesites.

Newerteststhathavebeenadvocatedforearlydiagnosisofsystemicfungalinfectioninclude:SandwichELISAforcirculatinggalactomannanPCRshowspromiseinthediagnosisofCandidainfections,evenunusualspecies.SURGICALINFECTION医疗专题知识专家讲座第31页TreatmentTherapytoetiology.Antifungaltherapy.

AmphotericinB0.5-1mg/kg.divFluconazoleandotherAzoles400mg/firstday,200-400mg/dSURGICALINFECTION医疗专题知识专家讲座第32页PreventionAppropriateapplyingantibioticsProphylacticapplyingantifungaldrugsSURGICALINFECTION医疗专题知识专家讲座第33页SURGICALINFECTION医疗专题知识专家讲座第34页Whatistetanus?Tetanusisanacute,sometimesfatal,diseaseofthecentralnervoussystem,causedbythetoxinofthetetanusbacterium,whichusuallyentersthebodythroughanopenwound.SURGICALINFECTION医疗专题知识专家讲座第35页PathogenesisTetanusresultsfrominfectionwithCtetani,amobile,spore-forming,anaerobic,

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

SURGICALINFECTION医疗专题知识专家讲座第36页PathogenesisThesporesofCtetanigerminateandproduce2toxins:tetanolysinandtetanospasmin.Theactionofthelatterhelpsexplaintheclinicalmanifestationsofthedisease.SURGICALINFECTION医疗专题知识专家讲座第37页PathogenesisTetanospasminissynthesizedasasingle151-kdchainandiscleavedtogeneratetoxinswith2chainsjoinedbyasingledisulfidebond.Theheavychain(100kd)isresponsibleforspecificbindingtoneuronalcellsandforproteintransport.Thelightchain(50kd)blocksthereleaseofneurotransmitters.

SURGICALINFECTION医疗专题知识专家讲座第38页PathogenesisOncethetoxinissynthesized,itmovesfromthecontaminatedsitetothespinalcordin2-14days.Whenthetoxinreachesthespinalcord,localizedorcephalictetanusmayoccurinitially,followedbygeneralizedtetanus.SURGICALINFECTION医疗专题知识专家讲座第39页ClinicalManifestationIncubation

Theincubationperiodfortetanusisusually2to14days,withmostsymptomsbeginningaroundthe7-8day,butonsetmayrangefrom24hoursto3weeks.SURGICALINFECTION医疗专题知识专家讲座第40页ClinicalManifestationTetanusoftenbeginswithmusclespasmsinthejaw(calledtrismus),accompaniedbydifficultyswallowingandstiffnessorpaininthemusclesoftheneck,shoulders,orback.Thesespasmscanspreadtothemusclesoftheabdomen,upperarms,andthighs.SURGICALINFECTION医疗专题知识专家讲座第41页Symptomsstiffnessofjaw(alsocalledlockjaw)difficultyswallowingcontractionoffacialmusclesstiffnessofabdominalandbackmusclesSweatingpainfulmusclespasmsnearthewoundarea(iftheseaffectthelarynxorchestwall,theymaycauseasphyxiation)

SURGICALINFECTION医疗专题知识专家讲座第42页PhysicalCommonfirstsignsoftetanusareheadacheandmuscularstiffnessinthejaw(ie,lockjaw),followedbyneckstiffness,difficultyswallowing,rigidityofabdominalmuscles,spasms,andsweating.Severetetanusresultsinopisthotonos,flexionofthearms,extensionofthelegs,periodsofapnearesultingfromspasmoftheintercostalmusclesanddiaphragm,andrigidityoftheabdominalwall.Lateinthedisease,autonomicdysfunctiondevelops,withhypertensionandtachycardiaalternatingwithhypotensionandbradycardia.SURGICALINFECTION医疗专题知识专家讲座第43页SURGICALINFECTION医疗专题知识专家讲座第44页SURGICALINFECTION医疗专题知识专家讲座第45页SURGICALINFECTION医疗专题知识专家讲座第46页

Complications

Themostcommoncomplicationisspasmofthevocalcordsand/orspasmsoftherespiratorymusclesthatcauseinterferencewithbreathing.Asphyxiation,pneumoniaOthercomplicationsincludemuscleavulsion,fractures,dislocationstachycardia,andheartfailure.SURGICALINFECTION医疗专题知识专家讲座第47页DIFFERENTIALS

RabiesEncephalitisStrychninepoisoning

OtherProblemstobeConsidered:

Dentalinfections

Localinfections

Hysteria

SURGICALINFECTION医疗专题知识专家讲座第48页

Prevention

Therearetwoimportantcomponentsoftetanusprevention:tetanusimmunization(receivingroutinetetanusvaccinations)andwhat'sknownaspost-exposuretetanusprophylaxis(receivingashotafteraninjuryoccurs).SURGICALINFECTION医疗专题知识专家讲座第49页

Prevention

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

ActiveimmunizationPost-exposuretetanusprophylaxisalsoinvolvesgettingtetanusshots,butafteraninjuryoccurs.

PassiveimmunizationSURGICALINFECTION医疗专题知识专家讲座第50页TreatmentThoroughcleaningofthewound

Neutronlizethefreetoxin

Passiveimmunizationwithhumantetanusimmuneglobulin(TIG)shortensthecourseoftetanusandmaylessenitsseverity.Adoseof500Uappearsaseffectiveaslargerdoses.OrTAT0-50000UIVSURGICALINFECTION医疗专题知识专家讲座第51页

TreatmentTocontrolspasms

Diazepamiv,10mgtid.Luminal0.1im.Physiciansalsousesedativehypnotics,narcotics,inhalationalanesthetics,neuromuscularblockingagents,andcentrallyactingmusclerelaxants(eg,intrathecalbaclofen).SURGICALINFECTION医疗专题知识专家讲座第52页TreatmentSecuringanadequateairway.Atracheotomyinseverecases(withrespiratoryproblems)Antibiotics

Metronidazole(eg,0.5gq6h)hascomparableorbetterantimicrobialactivity,andpenicillinisaknownantagonistofGABA,asistetanustoxin.SURGICALINFECTION医疗专题知识专家讲座第53页TreatmentSupportivetherapy

ParenteralnutritionIntensivenursingSURGICALINFECTION医疗专题知识专家讲座第54页TheappropriateapplicationofantibioticsSURGICALINFECTION医疗专题知识专家讲座第55页BackgroundTheglobalincreaseinresistancetoantimicrobialdrugs,includingtheemergenceofbacterialstrainsthatareresistanttoallavailableantibacterialagents,hascreatedapublichealthproblemofpotentiallycrisisproportions.SURGICALINFECTION医疗专题知识专家讲座第56页TheroleofantibioticsInhibitscellwallsynthesisImpairmentofbacterialDNAsynthesisDisruptionofmembranebarrierfunctionDisruptionofribosomalproteinsynthesisSURGICALINFECTION医疗专题知识专家讲座第57页ThecommonusedAntibioticsA.AmphotericinBB.PenicillinC.CephalosporinsD.β-lactamase:ImipenemE.AminoglycosidesF.QuinolonesG.ClindamycinH.Antianaerobic-microbacterialdrugsSURGICALINFECTION医疗专题知识专家讲座第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

SURGICALINFECTION医疗专题知识专家讲座第59页*AdministrationofprophylacticantibioticsChoiceofantibioticsTimingofadministrationDosageselectionDurationofprophylaxisRouteofadministrationSURGICALINFECTION医疗专题知识专家讲座第60页GuidelinesforUseChoiceofantibiotics

Theantibioticsselectedforprophylaxismustcovertheexpectedpathogensforthatoperativesite.Cephalosporin

Recommeded:

Cefuroxime(2ndgenerationcephalosporin)SURGICALINFECTION医疗专题知识专家讲座第61页GuidelinesforUseTimingofadministration

Givesingledoseinjection0-2hourspreoperation

ideallywithin30minutesoftheinductionofanaesthesiaDosageselection

Asinglestandardtherapeuticdoseofantibioticissufficientforprophylax