OBSTETRICS - Puerperal Infection

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OBSTETRICS - Puerperal Infection

  1. 1. nianderthalNOTESOBSTETRICS:PuerperalInfection
  2. 2. PUERPERAL INFECTION:IntroductionPUERPERAL INFECTIONa general term used to describe any bacterialinfection of the genital tract after delivery-PAST: constitutes the LETHAL TRIAD of maternaldeath, along with preeclampsia and obstetricalhemorrhage-PRESENT: maternal deaths from infection havebecome uncommon due to effectiveantimicrobials (13% of maternal deaths)
  3. 3. PUERPERAL INFECTION:Puerperal FeverPuerperal Fever-A temperature of 38.0°C or higher in the puerperium-Common causes of puerperal fever:1. Genital tract infection-Cause most persistent fevers after childbirth2. Breast engorgement-in 15% of women who don’t breastfeed-rarely exceeds 39.0°C3. Pyelonephritis-fever: first sign of renal infection-signs and symptoms that follow: costovertebralangle tenderness, nausea and vomiting
  4. 4. PUERPERAL INFECTION:Puerperal FeverPuerperal Fever-Common causes of puerperal fever:4. Respiratory complications after cesarean delivery-atelectasis: caused by hypoventilation andbest prevented by coughing and deepbreathing on a fixed schedule followingsurgery-fever: follows infection by normal flora thatproliferate distal to obstructing mucus plugs5. Superficial or deep-venous thrombosis of the legs-occasionally cause minor temperatureelevations in the puerperium
  5. 5. PUERPERAL INFECTION:Uterine Infection-Postpartum uterine infection has been calledvariously endometritis, endomyometritis andendoparametritis-Preferred term: metritis with pelvic cellulitis-because infection does not only involve thedecidua but also the myometrium and parametrialtissues
  6. 6. PUERPERAL INFECTION:Uterine InfectionPredisposing Factors1. Route of delivery-single most significant factor for the development of uterineinfection-25-fold increased infection-related mortality with cesarean versusvaginal delivery-manual removal of the placenta increase puerperal metritis 3-fold-metritis following vaginal delivery is relatively uncommonRISK FOR METRITISLow risk women without complications 1-2%High risk women due to membrane rupture,prolonged labor, and multiple cervical exams5-6%Women with intrapartum chorioamnionitis 13%
  7. 7. PUERPERAL INFECTION:Uterine InfectionPredisposing Factors1. Route of delivery-single-dose perioperative prophylaxis is given almost universally atcesarean delivery-Risk factors for infection following surgery include:-prolonged labor-membrane rupture-multiple cervical examinations-internal fetal monitoring-Increased risk of infection include cesarean delivery for:-multifetal gestation-young maternal age-nulliparity-prolonged labor induction-obestiy-meconium-stained amnionic fluid
  8. 8. PUERPERAL INFECTION:Uterine InfectionPredisposing Factors2. Lower socioeconomic status3. Anemia and Poor Nutrition-in very rare cases4. Previous bacterial colonization if the lower genitaltract with certain microorganisms like:-Group B streptococcus-Chlamydia trachomatis-Mycoplasma hominis-Ureaplasma urealyticum-Gardnerella vaginalis
  9. 9. PUERPERAL INFECTION:Uterine InfectionBacteriology-Most female pelvic infections are caused by bacteria indigenous tothe female genital tract-Reports show that group A -hemolytic streptococcus may causetoxic shock-like syndrome and life-threatening infection-Prematurely ruptured membranes is a prominent risk-Women in whom group A streptococcal infection was manifestedbefore, during, or within 12 hours of delivery had a maternalmortality rate of almost 90% and fetal mortality rate of >50%-Skin and soft-tissue infections due to community-acquiredmethicillin-resistant Staphylococcus aureus—CA-MRSA—havebecome common  NOT for puerperal metritis, but forincisional wound-Study: A woman with episiotomy cellulitis with CA-MRSA hadhematogenously spread necrotizing pneumonia
  10. 10. PUERPERAL INFECTION:Uterine InfectionCommon Pathogens-Infections are polymicrobial which promotes bacterial synergy-Other factors that promote virulence are hematomas anddevitalized tissue-The cervix and vagina routinely harbor such bacteria BUT theuterine cavity is usually sterile before rupture of the amnionicsac-The amnionic fluid and uterus commonly become contaminatedwith anaerobic and aerobic bacteria as the consequence oflabor and delivery and associated manipulations-Cultured amnionic fluid obtained at cesarean delivery in women inlabor with membranes ruptured more than 6 hours  all hadbacterial growth and an average of 2.5 organisms was identifiedfrom each specimen
  11. 11. PUERPERAL INFECTION:Uterine InfectionCommon Pathogens-Anaerobes included Peptostreptococcus and Peptococcus species,Bacteroides species and Clostridium species-Aerobes included Enterococcus, group B streptococcus, andEscherichia coli-Chlamydial infections have been implicated in late-onset, indolentmetritis-When cervical colonization of U. urealyticum is heavy, it maycontribute to the development of metritis- Threefold risk of puerperal infection in women in whombacterial vaginosis was identified in early pregnancy
  12. 12. PUERPERAL INFECTION:Uterine InfectionNORMAN FLORACERVICOVAGINAL BACTERIACervical ExaminationsInternal MonitoringProlonged LaborUterine incisionINNOCULATIONANAEROBIC CONDITIONSSurgical TraumaSuturesDevitalized TissueBlood and SerumCLINICAL INFECTIONBACTERIAL PROLIFERATION
  13. 13. PUERPERAL INFECTION:Uterine InfectionAerobes-Gram-positive cocci — group A, B, and D streptococci,enterococcus, Staphylococcus aureus, Staphylococcusepidermidis-Gram-negative bacteria — Escherichia coli, Klebsiella,Proteusspecies-Gram-variable — Gardnerella vaginalisOthers-Mycoplasma and Chlamydia species, Neisseria gonorrhoeaeAnaerobes-Cocci — Peptostreptococcus and Peptococcus species-Others — Clostridium and Fusobacterium species Mobiluncusspecies
  14. 14. PUERPERAL INFECTION:Uterine InfectionBacterial Cultures-Routine pretreatment genital tract cultures are oflittle clinical use and add significant costs-Routine blood cultures seldom modify care-Before perioperative prophylaxis: blood cultureswere positive in 13 percent of women withpostcesarean metritis-Bacteremia in only 5 percent of almost 800 womenwith puerperal sepsis.
  15. 15. PUERPERAL INFECTION:Pathogenesis-Puerperal infection following vaginal delivery primarilyinvolves:-placental implantation site-decidua and adjacent myometrium-cervicovaginal lacerations-The pathogenesis of uterine infection following cesareandelivery is that of an infected surgical incision-Bacteria that colonize the cervix and vagina gain access toamnionic fluid during labor and invade devitalized uterinetissue postpartum-Parametrial cellulitis next follows with infection of the pelvicretroperitoneal fibroareolar connective tissue-With early treatment, infection is contained within theparavaginal tissue but may extend deeply into the pelvis
  16. 16. PUERPERAL INFECTION:Clinical Course-Fever is the MOST IMPORTANT criterion for the diagnosis of postpartummetritis-Degree of fever is believed proportional to the extent of infection and sepsissyndrome-Temperatures commonly are 38 to 39°C-Chills that accompany fever suggest bacteremia-Women usually complain of:-abdominal pain-parametrial tenderness on abdominal and bimanual examination-offensive odor of lochia (but many women have foul-smelling lochiawithout evidence for infection)*those due to group A -hemolytic streptococci, are frequentlyassociated with scanty, odorless lochia-Leukocytosis may range from 15,000 to 30,000 cells/L*cesarean delivery itself increases the leukocyte count
  17. 17. PUERPERAL INFECTION:Treatment-Mild metritis following vaginal delivery: outpatient treatment with an oralantimicrobial agent is usually sufficient-Moderate to severe infections: intravenous therapy with a broad-spectrumantimicrobial regimen is indicated-Improvement follows in 48 to 72 hours in nearly 90% of women treatedwith one of several regimens-Persistent fever after 48 to 72 hours mandates a careful search for causesof refractory pelvic infection including:-Parametrial phlegmon—an area of intense cellulitis-Abdominal incisional or pelvic abscess-Infected hematoma-Septic pelvic thrombophlebitis-Antimicrobial-resistant bacteria or drug side effects  SELDOM-Patient may be discharged home after she has been afebrile for at least 24hours and further oral antimicrobial therapy is NOT needed
  18. 18. PUERPERAL INFECTION:TreatmentChoice of Antimicrobials-Although therapy is empirical, initial treatmentfollowing cesarean delivery is directed againstmost of the mixed flora which typically causepuerperal infections-Anaerobic coverage is included for infectionsfollowing cesarean delivery-Such broad-spectrum antimicrobial coverage isoften not necessary to treat infection followingvaginal delivery  respond to regimens such asampicillin plus gentamicin
  19. 19. PUERPERAL INFECTION:TreatmentAntimicrobial Regimens for Pelvic InfectionFollowing Cesarean DeliveryRegimen CommentsClindamycin 900 mg + gentamicin 1.5mg/kg, q8h intravenously"Gold standard" 90–97% efficacy, once-daily gentamicin dosing acceptable+Ampicillin added to regimen with sepsissyndrome or suspected enterococcalinfectionClindamycin + aztreonam Gentamicin substitute with renalinsufficiencyExtended-spectrum penicillins Piperacillin, ampicillin/sulbactamExtended-spectrum cephalosporins Cefotetan, cefoxitin, cefotaximeImipenem + cilastatin Reserved for special indications
  20. 20. PUERPERAL INFECTION:TreatmentChoice of Antimicrobials-Clindamycin-gentamicin – 95% response rate, and this regimen-still considered by most to be the standard by which others aremeasured-Enterococcal infections: add ampicillin to the clindamycin-gentamicinregimen, either initially or if there is no response by 48 to 72 hours-Serum gentamicin levels be periodically monitored or only with alteredrenal function*Once-daily dosing has a cure rate similar to 8-hour dosing-Gentamicin: potential nephrotoxicity and ototoxicity in the event ofdiminished glomerular filtration-Alternatives in altered renal function:-Clindamycin and a second-generation cephalosporin-Clindamycin and aztreonam (monobactam with aminoglycoside-likeaction)
  21. 21. PUERPERAL INFECTION:TreatmentChoice of Antimicrobials-The spectra of -lactam antimicrobials include activity against many anaerobicpathogens and are inherently safe and free of major toxicity except for allergicreactions-cephalosporins such as cefoxitin, cefotetan, and cefotaxime-extended-spectrum penicillins such as piperacillin, ticarcillin, and mezlocillin-The -lactamase inhibitors, clavulanic acid, sulbactam, and tazobactam, have beencombined with ampicillin, amoxicillin, ticarcillin, and piperacillin to extendspectra of lactams-Metronidazole has superior in vitro activity against most anaerobes-Given with ampicillin and an aminoglycoside to provide coverage against mostorganisms encountered in serious pelvic infections-Imipenem is a carbapenem that has broad-spectrum coverage against mostorganisms associated with metritis-Used with cilastatin, which inhibits renal metabolism of imipenem*Combination is effective in most cases of metritis, it seems reasonablefrom both a medical and an economic standpoint to reserve it for more seriousinfections
  22. 22. PUERPERAL INFECTION:PreventionPerioperative Antimicrobial Prophylaxis-Administration of antimicrobial prophylaxis at the time of cesareandelivery  reduce the rate of pelvic infection by 70 to 80*Observed benefit applies to both elective and nonelectivecesarean delivery and also includes a reduction in abdominalincisional infections-Single-dose prophylaxis with ampicillin or a first-generationcephalosporin is ideal, and both are as effective as broad-spectrumagents or a multiple-dose-Extended-spectrum prophylaxis with azithromycin added to standardsingle-dose prophylaxis showed a significant reduction inpostcesarean metritis-Women known to be colonized with methicillin-resistantStaphylococcusaureus—MRSA—are given vancomycin in additionto a cephalosporin
  23. 23. PUERPERAL INFECTION:PreventionPerioperative Antimicrobial Prophylaxis-Infection rate is lowered more if the selected antimicrobial is givenbefore the skin incision compared with cord clamping-A number of locally applied antimicrobials have been evaluated toprevent puerperal infection-Intrapartum vaginal irrigation with chlorhexidine did not reducethe incidence of postpartum infection-Conflicting studies on use of Povidone-iodine:-vaginal irrigation before cesarean delivery had no effect onthe incidence of fever, metritis, or abdominal incisional infection-Preoperative vaginal cleansing with povidone-iodine hada significantly lower infection rate following cesareandelivery—7 versus 14 percent-Metronidazole gel: reduction in rate of metritis but no significanteffect on febrile morbidity or wound infections
  24. 24. PUERPERAL INFECTION:PreventionTreatment of Vaginitis-Prenatal treatment of asymptomatic vaginal infections hasnot been shown to prevent postpartum pelvic infections-No beneficial effects for women treated for asymptomaticbacterial vaginosis-Similar postpartum infection rate in women treated for 2ndtrimester asymptomatic Trichomonas vaginalis infectioncompared with that of placebo-treated women
  25. 25. PUERPERAL INFECTION:PreventionOperative Technique-Allowing the placenta to separate spontaneously compared withremoving it manually lowers the risk of infection-Changing gloves by the surgical team after placental delivery DOESNOT lower infection rates-Exteriorizing the uterus to close the hysterectomy may decreasefebrile moridity-Single versus 2-layer uterine closure: no difference inpostoperative infection rate-Closure versus Non-closure of Peritoneum: no effect on infectionrates-Closure of subcutaneous tissue in obese women: does NOT lowerinfection rate but LOWERS incidence of wound separation
  26. 26. PUERPERAL INFECTION:Complications of Pelvic InfectionsWound Infection-When prophylactic antimicrobials are given, incidence ofabdominal incisional infections following Cesarean delivery isless than 2%-Wound infection is a common cause of persistent fever in womentreated for metritis-Risk factors:-Obesity-Diabetes-Corticosteroid therapy-Immunosuppression-Anemia-Hypertension-Inadequate hemostasis with hematoma formation
  27. 27. PUERPERAL INFECTION:Complications of Pelvic InfectionsWound Infection-Incisional abscesses that develop following cesarean deliveryusually cause fever or cause persisting fever beginning on the 4thday – may be accompanied by wound erythema and drainage-Treatment for abscess include antimicrobials and surgicaldrainage, with careful inspection to ensure that fascia is intact-Wound care given 2-3 times daily: secondary en bloc closure at 4-6 days of tissue involved in superficial wound infection-After closure: polypropylene or nylon suture of appropriate gaugeenters 3 cm from one wound edge  crosses the wound toincorporate the full wound thickness  emerges 3 cm from theother wound edge – placed in series to close the opening-Sutures may be removed on postprocedural day 10
  28. 28. PUERPERAL INFECTION:Complications of Pelvic InfectionsWound Dehiscence-Disruption or Dehiscence refers to separation of the fasciallayer-Requires secondary closure of the incision in the operatingroom-Most disruptions manifested on 5th postoperative day andis often accompanied by a serosanguineous discharge-May be associated with concurrent fascial infection andtissue necrosis
  29. 29. PUERPERAL INFECTION:Complications of Pelvic InfectionsNecrotizing Fasciitis of Abdominal Wall Incisions-Uncommon, severe wound infection with necrosis associated withhigh mortality-may involve abdominal incisions, or may complicate episiotomy orother perineal lacerations-Risk factors: Diabetes, Obesity, Hypertension-Usually are polymicrobial and are caused by organisms thatcomprise normal vaginal flora-Can also be caused by single virulent bacterial species such asgroup A β-hemolytic streptococcus-Treatment consists of broad-spectrum antibiotics along withprompt fascial debridement until healthy bleeding tissue isencountered-In extensive resection, synthetic mesh may be required
  30. 30. PUERPERAL INFECTION:Complications of Pelvic InfectionsPeritonitis-unusual to develop following cesarean delivery-invariably preceded by metritis and uterine incisional necrosis anddehiscence-may be due to:-inadvertent bowel injury at cesarean delivery-after rupture of parametrial or adnexal abscess-vaginal delivery (very rare)-Abdominal rigidity MAY NOT be prominent with puerperal peritonitisbecause of abdominal wall laxity from pregnancy-Severe pain may be experienced, but FIRST SYMPTOM is frequentlyadynamic ileus-Bowel distention may develop-Treatment: antimicrobial treatment alone may suffice for infections thatbegin with an intact uterus and extend to peritoneum-surgical treatment is for peritonitis caused by uterine incisional necoris orbowel perforation
  31. 31. PUERPERAL INFECTION:Complications of Pelvic InfectionsAdnexal Infections-Ovarian abscess rarely develops in the puerperium-Presumed to be caused by bacterial invasion through a rentin the ovarian capsule-Usually unilateral-Present 1-2 weeks after delivery-Rupture is common and peritonitis may be severe
  32. 32. PUERPERAL INFECTION:Complications of Pelvic InfectionsParametrial Phlegmon-Phlegmon: an area of induration within the leaves of thebroad ligament in those with parametrial cellulitis-Develops following cesarean delivery in women withmetritis-Considered when fever persists after 72 hours despite IVantibiotics-Phlegmons are usually unilateral, frequently limited to theparametrial area at the base of the broad ligament-In intense cases, cellulitis extends along natural lines ofcleavage – most common of which is laterally along broadligament with tendency to extend to pelvic sidewall-Posterior extension may involve rectovaginal septum,producing a firm mass on the cervix
  33. 33. PUERPERAL INFECTION:Complications of Pelvic InfectionsParametrial Phlegmon-Severe cellulitis of uterine incision may lead tonecrosis and separation-Puerperal metritis with cellulitis: typically aretroperitoneal infection  evidence of peritonitissuggests possibility of uterine incisional necrosis,bowel injury, or other lesions-Treatment: broad-spectrum antimicrobial regimen*Fever resolves in 5-7 days but may last longer-surgery is reserved for uterine incisional necrosis-uterine debridement and resuturing are feasible
  34. 34. PUERPERAL INFECTION:Complications of Pelvic InfectionsImaging Studies-Persistent puerperal infections can be evaluated usingcomputed tomography (CT) or magnetic resonance (MR)imaging-Uterine incisional dehiscence is sometimes suspected by CTscanning images but these must be interpreted within theclinical context because apparent uterine incisionaldefects thought to represent edema can be seen even onimages after uncomplicated cesarean delivery
  35. 35. PUERPERAL INFECTION:Complications of Pelvic InfectionsPelvic Abscess-Rarely, a parametrial phlegmon suppurates, forming afluctuant broad ligament mass that may point above theinguinal ligament-Abscesses may dissect:-anteriorly - amenable to CT-directed needle drainage-posteriorly to the rectovaginal septum - surgical drainageis easily effected by colpotomy incision-Psoas abscess: rare, may require percutaneous drainagedespite antimicrobial therapy
  36. 36. PUERPERAL INFECTION:Complications of Pelvic InfectionsSeptic Pelvic Thrombophlebitis-common complication in the preantibotic era-Pathogenesis: puerperal infection may extend along venous routesand cause thrombosis-Lymphangitis often coexists-Ovarian veins may become involved because they drain the upperuterus and therefore, the placental implantation site-Puerperal septic thrombophlebitis is likely to involve one or bothovarian venous plexuses-Clot may extend into the inferior vena cava and occasionally to therenal vein
  37. 37. PUERPERAL INFECTION:Complications of Pelvic InfectionsSeptic Pelvic Thrombophlebitis-Incidence:-1:9000 - following vaginal delivery-1:800 - with cesarean delivery-Overall incidence of 1:3000-Management:-Women with septic thrombophlebitis usually have clinicalimprovement of pelvic infection with antimicrobial treatment butthey continue to have fever-Occasionally there is pain in one or both lower quadrants butpatients are usually asymptomatic except for chills.-Diagnosis can be confirmed by either pelvic CT or MR imaging-Before imaging methods were available, the heparin challenge testwas advocated
  38. 38. PUERPERAL INFECTION:Complications of Pelvic InfectionsInfections of the Perineum, Vagina, and Cervix-Episiotomy infections are NOT common because the operation isperformed much less frequently now than in the past-With infection, dehiscence is a concern - 0.5% of episiotomy woundsdehisced and 80% of these were due to infection-Infection of a fourth-degree laceration is likely to be more serious-Although life-threatening septic shock is rare, it may still occur as aresult of an infected episiotomy-Pathogenesis and Clinical Course:-Factors associated to episiotomy dehiscence:-infection-coagulation disorders-smoking-HPV infection
  39. 39. PUERPERAL INFECTION:Complications of Pelvic InfectionsInfections of the Perineum, Vagina, and Cervix-Pathogenesis and Clinical Course:-Common symptoms of episiotomy dehiscence:-Local pain 65%-Purulent discharge 65%-Fever 44%-dysuria, with or without urinary retention-Edema, ulceration and exudation of the vulva
  40. 40. PUERPERAL INFECTION:Complications of Pelvic InfectionsInfections of the Perineum, Vagina, and Cervix-Pathogenesis and Clinical Course:-Vaginal lacerations may become infected directly or by extensionfrom the perineum  mucosa becomes red and swollen and maythen become necrotic and slough-Parametrial extension may result in lymphangitis.-Cervical lacerations are common but seldom are noticeablyinfected and may manifest as metritis-Deep lacerations which extend directly into the tissue at the baseof the broad ligament may become infected and causelymphangitis, parametritis, and bacteremia
  41. 41. PUERPERAL INFECTION:Complications of Pelvic InfectionsInfections of the Perineum, Vagina, and Cervix-Treatment:-Infected episiotomies are managed like other infected surgicalwounds-Drainage is established-Sutures are removed-Infected wound debrided-Cellulitis but NO purulence: broad-spectrum antimicrobial therapywith close observation-Dehiscence: local wound care is continued along with intravenousantimicrobials-Early repair after infection subsided is advocated - averageduration of 6 days from dehiscence to episiotomy repair-Rarely, intestinal diversion may be required to allow healing
  42. 42. PUERPERAL INFECTION:Complications of Pelvic InfectionsInfections of the Perineum, Vagina, and Cervix-Technique for Early Repair:Before performing early repair, diligent preparation is essentialPREOPERATIVE PROTOCOL for Early Repair of Episiotomy Dehiscence1. Open wound, remove sutures, begin intravenous antimicrobials2. Wound care-Sitz bath several times daily or hydrotherapy-Adequate analgesia or anesthesia—regional analgesia or general anesthesiamay be necessary for the first few debridements-Scrub wound twice daily with a povidone-iodine solution-Debride necrotic tissue3. Closure when afebrile and with pink, healthy granulation tissue4. Bowel preparation for fourth-degree repairs
  43. 43. PUERPERAL INFECTION:Complications of Pelvic InfectionsInfections of the Perineum, Vagina, and Cervix-Technique for Early Repair:-Most important is that the surgical wound must be properlycleaned and free of infection-Surface of the episiotomy wound free of infection & exudate andcovered by pink granulation tissue  secondary repair can be done-Tissue must be adequately mobilized, with special attention toidentify and mobilize the anal sphincter muscle-Secondary closure of the episiotomy is accomplished in layers-Postoperative care includes:-local wound care-low-residue diet-stool softeners-nothing per vagina or rectum until healed
  44. 44. PUERPERAL INFECTION:Complications of Pelvic InfectionsInfections of the Perineum, Vagina, and Cervix-Necrotizing Fasciitis of Perineal and Vaginal Wound Infections-Fatal complication of perineal and vaginal wound infections is deepsoft-tissue infection involving muscle and fascia-Common in women with diabetes or those immunocompromisedbut may develop in otherwise healthy women-Microbiology is similar to those of other pelvic infections, as wellas necrotizing fasciitis of the abdominal wall incision-Necrotizing fasciitis of the episiotomy site may involve any of theseveral superficial or deep perineal fascial layers  may extend tothe thighs, buttocks, and abdominal wall-Early Postpartum: Group A β-hemolytic streptococci infectionstypically do NOT cause symptoms until 3 to 5 days after delivery
  45. 45. PUERPERAL INFECTION:Complications of Pelvic InfectionsInfections of the Perineum, Vagina, and Cervix-Necrotizing Fasciitis of Perineal and Vaginal Wound Infections-If myofasciitis progresses, the woman may become ill fromsepticemia  profound hemoconcentration from capillary leakagewith circulatory failure commonly occurs  death-Early diagnosis, surgical debridement, antimicrobials, and intensivecare are of paramount importance in the successful treatment ofnecrotizing soft-tissue infections-Surgery includes extensive debridement of all infected tissue, leavingwide margins of healthy tissue including extensive vulvardebridement with unroofing and excision of abdominal, thigh, orbuttock fascia-Mortality is virtually universal without surgical treatment, and ratesapproach 50% even if extensive debridement is performed
  46. 46. PUERPERAL INFECTION:Toxic Shock Syndrome-Acute febrile illness with severe multisystem derangement has acase-fatality rate of 10-15%-Presents usually with:-Fever-Headache-Mental confusion-Diffuse macular erythematous rash-Subcutaneous edema-Nausea and vomiting-Watery diarrhea-Marked hemoconcentration-Renal failure followed by hepatic failure, disseminated intravascularcoagulation, and circulatory collapse may follow in rapid sequence
  47. 47. PUERPERAL INFECTION:Toxic Shock Syndrome-During recovery, the rash-covered areas undergo desquamation-Staphylococcus aureus has been recovered from almost all afflictedpersons specifically, a staphylococcal exotoxin, termed toxicshock syndrome toxin-1-TSST-1—causes the clinical manifestations by provoking profoundendothelial injury-A very small amount of TSST-1 has been shown to activate 5-30%of T cells to create a "cytokine storm”-Other possible causes: Clostridium sordellii colonization, group A β-hemolytic streptococcal infection (more virulent serotypes: M1,M3)
  48. 48. PUERPERAL INFECTION:Toxic Shock Syndrome-Delayed diagnosis and treatment may be associated with fetal ormaternal mortality-Principal therapy for toxic shock is supportive, while allowingreversal of capillary endothelial-Antimicrobial therapy to include staphylococcal and streptococcalcoverage is given-With evidence of pelvic infection, antimicrobial therapy must alsoinclude agents used for polymicrobial infections-Women with these infections often require extensive wounddebridement and possibly hysterectomy

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