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Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
Infection and Sepsis
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Infection and Sepsis

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  • 1. INFECTION AND SEPSIS <ul><li>Surrounded by pathogens </li></ul><ul><li>Infection is the exception </li></ul><ul><li>Protective from infection </li></ul><ul><ul><li>Physical barriers </li></ul></ul><ul><ul><li>Chemical barriers </li></ul></ul><ul><ul><li>Immunological function </li></ul></ul>
  • 2. Physical and Chemical Barriers to Infection <ul><li>Skin </li></ul><ul><ul><li>stronger in hands and feet </li></ul></ul><ul><ul><li>sebaceous secretions lower pH </li></ul></ul><ul><li>Mucous membranes </li></ul><ul><ul><li>ciliary function </li></ul></ul><ul><ul><li>mucous barrier </li></ul></ul><ul><ul><li>acid mileu in stomach </li></ul></ul>
  • 3. Barriers breached in Surgery
  • 4. Barriers Breached in Trauma
  • 5. Immune Defense <ul><li>Humoral defense </li></ul><ul><ul><li>antibodies </li></ul></ul><ul><ul><li>complement </li></ul></ul><ul><li>Cellular defense </li></ul><ul><li>Cytokines </li></ul><ul><ul><li>potential for deleterious effects </li></ul></ul><ul><li>Interaction of mechanisms </li></ul>
  • 6. Breakdown of Host Defense <ul><li>Physical, chemical and immunological breakdown -act synergistically </li></ul><ul><li>e.g. patient with </li></ul><ul><ul><li>diabetes </li></ul></ul><ul><ul><li>immunosuppresion </li></ul></ul><ul><ul><li>surgery </li></ul></ul><ul><li>Potential for deleterious effects </li></ul>
  • 7. Fourniers Gangrene
  • 8. Commensal Microbial Flora <ul><li>Important for immune development </li></ul><ul><li>Occupy binding sites for pathogens </li></ul><ul><li>Provide mucobacterial barrier </li></ul><ul><li>Anerobic bacteria </li></ul><ul><ul><li>present in greatest quantity in GIT </li></ul></ul><ul><ul><li>Greatest diversity </li></ul></ul><ul><ul><li>Prevent invasion by gram neg. aerobes </li></ul></ul>
  • 9. Breakdown of Host Defense - GIT Flora <ul><li>Transmigration of bacteria </li></ul><ul><ul><li>Lack of feeding </li></ul></ul><ul><ul><li>Overuse of antibiotics </li></ul></ul><ul><ul><li>Absence of bile </li></ul></ul><ul><ul><li>Protein malnutrition </li></ul></ul><ul><ul><li>Immune deficiency </li></ul></ul>
  • 10. ICU patient fed enteraly To preserve GIT integrity
  • 11. Infection Manifestation <ul><li>Local signs </li></ul><ul><ul><li>pain,redness,swelling, warmth loss of function </li></ul></ul><ul><li>Systemic signs </li></ul><ul><ul><li>Fever, somnolence, confusion, ileus, hypotension </li></ul></ul><ul><li>Lab tests </li></ul><ul><ul><li>TW,­polymorphs, Cultures </li></ul></ul><ul><li>Non infective- causes may manifest as infection </li></ul>
  • 12. Common Infections <ul><li>Wound infection </li></ul><ul><li>Initial inoculum overwhelms host defense </li></ul><ul><ul><li>Occurs at 5 - 7 days post op </li></ul></ul><ul><li>Factors </li></ul><ul><ul><li>host - immune suppression, DM, renal failure </li></ul></ul><ul><ul><li>surgeon - technique </li></ul></ul><ul><ul><li>environment - contamination </li></ul></ul>
  • 13. Common Infections <ul><li>Types of Wounds </li></ul><ul><li>1. Clean - no viscus, no sterile breach </li></ul><ul><li>2. Clean contaminated - controlled entry into viscus </li></ul><ul><li>3. Contaminated - emergency bowel resection, perforated appendix </li></ul><ul><li>4. Dirty - heavy contamination / long duration </li></ul><ul><li>Antibiotics used </li></ul><ul><ul><li>type 2 as prophylaxis </li></ul></ul><ul><ul><li>type 3,4 as treatment </li></ul></ul>
  • 14. Wound Closure <ul><li>Wounds </li></ul><ul><li>Closure by </li></ul><ul><ul><li>primary intention </li></ul></ul><ul><ul><li>secondary intention </li></ul></ul><ul><li>Timing of closure </li></ul><ul><ul><li>delayed primary closure </li></ul></ul><ul><ul><li>secondary closure </li></ul></ul>
  • 15. Closure by Secondary Intention
  • 16. Intraabdominal Infection <ul><li>Defense </li></ul><ul><ul><li>Bacterial clearance - stomata between mesothelial cells under diaphragm lead to lymph vessels </li></ul></ul><ul><ul><li>Phagocytosis - both resident and recruited phagocytes </li></ul></ul><ul><ul><li>Sequestration - by fibrin rich inflammatory exudate, with omentum/viscera </li></ul></ul>
  • 17. Intraabdomianal Infection <ul><li>Signs of peritonitis </li></ul><ul><li>Pain </li></ul><ul><ul><li>sharp in character, well localised at first </li></ul></ul><ul><ul><li>spreads to surrounding areas </li></ul></ul><ul><ul><li>involuntary guarding, rigidity </li></ul></ul><ul><ul><li>absent bowel sounds </li></ul></ul><ul><li>Posture </li></ul><ul><ul><li>lying still, rapid breathing ,no movement </li></ul></ul><ul><li>General condition </li></ul><ul><ul><li>ill, septic, dehydrated, hypotension </li></ul></ul>
  • 18. Intraabdominal Infection <ul><li>Usually viscus perforation </li></ul><ul><ul><li>colon worse than upper GIT </li></ul></ul><ul><li>Isolates </li></ul><ul><ul><li>aerobic - E. Coli, klebsiella other enterobacter, strep, enterococci, proteus, pseudomonas </li></ul></ul><ul><ul><li>anaerobic - bacteroides, Clostridium </li></ul></ul><ul><li>Treatment is surgical and aggressive antibiotic treatment </li></ul>
  • 19. Enterocutaneous Fistula
  • 20. <ul><li>Pneumonia </li></ul><ul><ul><li>Protein malnourished </li></ul></ul><ul><ul><li>upper abdominal wounds ® poor cough </li></ul></ul><ul><ul><li>bed bound - atelectasis </li></ul></ul><ul><ul><li>elderly </li></ul></ul><ul><ul><li>ventilator </li></ul></ul><ul><li>Occurs from 3 days post op </li></ul><ul><ul><li>careful clinical exam,CXR </li></ul></ul><ul><ul><li>Routine chest physiotherapy </li></ul></ul>Common Post Surgical Infections
  • 21. <ul><li>Urinary Tract Infection </li></ul><ul><ul><li>catheters </li></ul></ul><ul><ul><li>dehydration </li></ul></ul><ul><li>Remove catheters early </li></ul><ul><li>Ensure hydration </li></ul><ul><li>Antimicrobial therapy </li></ul>Common Post Surgical Infections
  • 22. <ul><li>Catheter and prosthetic devices </li></ul><ul><ul><li>I/v canulas </li></ul></ul><ul><ul><li>central lines </li></ul></ul><ul><ul><li>mesh </li></ul></ul><ul><li>Skin organisms- S aureus, S epidermidis </li></ul><ul><li>Aseptic technique </li></ul><ul><li>Remove if infected </li></ul>Common Post Surgical Infections
  • 23. Less Common Post Surgical Infections <ul><li>Necrotising soft tissue infection </li></ul><ul><li>Parotitis </li></ul><ul><li>Sinusitis </li></ul><ul><li>Tonsillitis </li></ul>
  • 24. Treatment of Infection <ul><li>General principles </li></ul><ul><ul><li>incise and drain pus </li></ul></ul><ul><ul><li>antibiotics as needed </li></ul></ul><ul><ul><li>debride dead tissue </li></ul></ul><ul><ul><li>remove foreign bodies </li></ul></ul>
  • 25. Antibiotic Therapy <ul><li>Prophylaxis </li></ul><ul><ul><li>Short course to prevent infection </li></ul></ul><ul><ul><li>Must be on board before contamination </li></ul></ul><ul><ul><li>Antibiotics with activity against expected inoculation organisms </li></ul></ul><ul><ul><li>Avoid extended spectrum agents </li></ul></ul><ul><ul><li>Post op benefit not proven </li></ul></ul><ul><ul><li>Topical antibiotics - not proven </li></ul></ul>
  • 26. Antibiotic Therapy <ul><li>Empirical therapy </li></ul><ul><ul><li>based on clinical information </li></ul></ul><ul><ul><li>search for source must continue </li></ul></ul><ul><ul><li>limit duration of empirical therapy </li></ul></ul><ul><ul><li>use known institution pattern of infection </li></ul></ul><ul><ul><li>multi agent vs broad agent </li></ul></ul>
  • 27. Antibiotic Therapy <ul><li>Directed therapy </li></ul><ul><ul><li>target identified pathogens </li></ul></ul><ul><ul><li>choose suitable efficacy /minimal toxicity agent </li></ul></ul><ul><ul><li>cover aerobic and anaerobic if likelihood exist for both </li></ul></ul><ul><ul><li>extended spectrum as last resort </li></ul></ul>
  • 28. Multiple System Organ Failure <ul><li>AKA - Gram neg. bacterial sepsis </li></ul><ul><li>30% mortality </li></ul><ul><li>Healthy and compromised host </li></ul><ul><li>3-13 cases per 1000 admissions </li></ul><ul><li>Nosocomial </li></ul>
  • 29.  
  • 30. <ul><li>Factors </li></ul><ul><ul><li>Host compromise </li></ul></ul><ul><ul><li>Elderly, disability </li></ul></ul><ul><ul><li>Malnutrition </li></ul></ul><ul><ul><li>Antimicrobial therapy </li></ul></ul><ul><ul><li>Major surgery </li></ul></ul><ul><ul><li>Cavity manipulation </li></ul></ul><ul><ul><li>Immunosuppression e.g. steroids </li></ul></ul>Multiple System Organ Failure
  • 31. MSOF <ul><li>Fever </li></ul><ul><li>Acidosis, hypoxemia </li></ul><ul><li>Disordered oxygen and substrate use </li></ul><ul><li>Hyperglycaemia </li></ul><ul><li>Decreased systemic vascular resistance </li></ul><ul><li>Elevated cardiac output </li></ul><ul><li>Hypotension </li></ul>
  • 32. MSOF <ul><li>Evidence for LPS - endotoxin </li></ul><ul><li>LPS </li></ul><ul><ul><li>O antigen - specific for each organism </li></ul></ul><ul><ul><li>core LPS </li></ul></ul><ul><ul><li>membrane lipid A </li></ul></ul>
  • 33. LPS - EFFECTS <ul><li>non specific polyclonal b cell proliferation </li></ul><ul><li>macrophage activation, cytokine release </li></ul><ul><li>hypotension, hypoxemia </li></ul><ul><li>bacterial translocation </li></ul><ul><li>complement and coagulation activation </li></ul><ul><li>platelet and white cell margination </li></ul>
  • 34. LPS - Mechanism <ul><li>Direct effect of bacteria </li></ul><ul><li>Indirect (mediated) effect </li></ul><ul><ul><li>trigger macrophages to release TNFa, IL-1, IL-6, aIFN </li></ul></ul><ul><ul><li>TNFa, IL-1, - primary mediators but may be deleterious in large amounts </li></ul></ul><ul><ul><li>aIFN- causes continued activation of macrophages </li></ul></ul><ul><ul><li>Permeability defects in microcirculation </li></ul></ul><ul><ul><li>ARDS, GUT, Hepatic, renal failure </li></ul></ul>
  • 35. Problem <ul><li>A 23 year old man had a perforated appendix. Three days post op this was his temperature chart. What is your interpretation. </li></ul>
  • 36. Problem <ul><li>What is your choice for antibiotic prophylaxis for </li></ul><ul><ul><li>colorectal surgery </li></ul></ul><ul><ul><li>biliary surgery </li></ul></ul><ul><ul><li>upper GI surgery </li></ul></ul>
  • 37. Problem <ul><li>A 75 year old diabetic had an operation for perforated diverticular disease. His wound was found to be infected on the 5th POD. </li></ul><ul><li>What factors may have contributed to this? </li></ul>
  • 38.  

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