Recommended
More Related Content
Similar to surgicalinfection-180604172906.pdf
Similar to surgicalinfection-180604172906.pdf (20)
More from Ogunsina1
More from Ogunsina1 (20)
Recently uploaded
Recently uploaded (20)
surgicalinfection-180604172906.pdf
- 2. Definition of surgical infection Definition of surgical infection Infection which may need surgical intervention or caused by surgical procedure
- 3. Classification Classification Acute infection Acute infection Acute abscess Acute abscess Cellulitis Cellulitis Bacteraemia Bacteraemia Septicaemia Septicaemia Pyaemia Pyaemia Boils Boils Carbuncles Carbuncles Tetanus Tetanus Gas gangrene Gas gangrene Chronic infection Chronic infection Tuberculosis Tuberculosis
- 6. Definition Definition Abscess Abscess is a localised collection of pus. is a localised collection of pus. Pus Pus is composed of dead and dying white blood cells. is composed of dead and dying white blood cells. pyogenic membrane pyogenic membrane Area immediately around the abscess Area immediately around the abscess Composed of fibrinous exudates and oedema, and the cells of Composed of fibrinous exudates and oedema, and the cells of acute inflammation. acute inflammation. Abscess is surrounded by an acute inflammatory Abscess is surrounded by an acute inflammatory response response
- 7. Granulation tissue Granulation tissue Composed of macrophages, angiogenesis and Composed of macrophages, angiogenesis and fibroblasts fibroblasts Forms around the suppuration and leads to collagen Forms around the suppuration and leads to collagen deposition. deposition.
- 8. Chronic abscess Chronic abscess Results from excessive granulation or partly Results from excessive granulation or partly sterilised by antibiotics (antibioma) sterilised by antibiotics (antibioma) Certain organisms are related Certain organisms are related Mycobacteria and actinomycosis Mycobacteria and actinomycosis Lymphocytes and plasma cells are seen with Lymphocytes and plasma cells are seen with sequestration and later calcification sequestration and later calcification. . Persistent chronic abscess may lead to sinus or Persistent chronic abscess may lead to sinus or fistula formation. fistula formation.
- 9. Causal organism Causal organism Staphylococcus aureus Staphylococcus aureus Source of infection Source of infection Direct infection from without Direct infection from without Local extension Local extension Lymphatics Lymphatics Blood-stream Blood-stream
- 10. Clinical features Clinical features Clinical features of acute inflammation. Clinical features of acute inflammation. Pain, swelling, redness, increased temperature, loss Pain, swelling, redness, increased temperature, loss of function of function Abscess usually tract along planes of least Abscess usually tract along planes of least resistance and point towards the skin. resistance and point towards the skin.
- 11. Treatment Incision and drainage Incision and drainage Debridement and curettage with an exploration Debridement and curettage with an exploration to breakdown all loculi to breakdown all loculi Antibiotics Antibiotics There are signs of spreading infection There are signs of spreading infection cellulitis or lymphangitis cellulitis or lymphangitis
- 12. Deep cavity abscess Deep cavity abscess Difficult to diagnose Difficult to diagnose Ultrasonography, CT, MRI and isotope scanning Ultrasonography, CT, MRI and isotope scanning Accurate for diagnosis Accurate for diagnosis Allow guided aspiration Allow guided aspiration
- 14. Definition Definition Spreading inflammation of connective tissue Spreading inflammation of connective tissue along subcutaneous tissue and fascial planes along subcutaneous tissue and fascial planes
- 15. Causal organisms Causal organisms Streptococcus pyogenes Streptococcus pyogenes Organisms enter through accidental wound, graze or scratch Organisms enter through accidental wound, graze or scratch Caused by Caused by Minor trauma Minor trauma Surgical incision Surgical incision Insect bites Insect bites Burns Burns Around infected wound Around infected wound Around cutaneous ulcer Around cutaneous ulcer
- 16. Predisposing factors Predisposing factors Diabetes Diabetes Renal insufficiency Renal insufficiency Alcoholism Alcoholism
- 17. Clinical features Clinical features Pain, swelling, itchiness and stiffness Pain, swelling, itchiness and stiffness Fever Fever Swelling, diffuse with indefinite edges Swelling, diffuse with indefinite edges Sings and symptoms of inflammation Sings and symptoms of inflammation
- 18. Treatment Treatment Rest, elevation of affected pats Rest, elevation of affected pats Appropriate broad spectrum antibiotics Appropriate broad spectrum antibiotics If pus is suspected If pus is suspected Free incision made in the axis of limb down to deep Free incision made in the axis of limb down to deep fascia fascia Control of predisposing factors Control of predisposing factors
- 19. Cellulitis in special situations Cellulitis in special situations Ludwig’s angina Ludwig’s angina Generalised cellulites of submandibular region Generalised cellulites of submandibular region Haemolytic streptococci Haemolytic streptococci Both the aerobic and anaerobic organisms are causal Both the aerobic and anaerobic organisms are causal Spread of infection Spread of infection Due to extraction of molar tooth because root of molar Due to extraction of molar tooth because root of molar lies below the mylohyoid muscle, through this lies below the mylohyoid muscle, through this extraction some organisms localized under mouth extraction some organisms localized under mouth
- 20. Clinical features Clinical features Browny induration of submandibular region Browny induration of submandibular region Does not pit on pressure Does not pit on pressure No fluctuation No fluctuation Sharp demarcation between abnormal skin and surrounding Sharp demarcation between abnormal skin and surrounding normal skin normal skin Bilateral involvement of Bilateral involvement of Submental space Submental space Submandibular space Submandibular space Respiratory distress Respiratory distress
- 21. Fever with chills and rigor Fever with chills and rigor Increased salivation Increased salivation Foul breath (foetor oris) Foul breath (foetor oris) Stiffness of tongue (dysathria) Stiffness of tongue (dysathria) Oedema of larynx (dyspnoea) Oedema of larynx (dyspnoea)
- 22. Treatment Treatment If diagnosed early If diagnosed early High dose of antibiotic therapy High dose of antibiotic therapy If swelling does not subside by antibiotic If swelling does not subside by antibiotic Incision and drainage Incision and drainage In late condition In late condition Tracheostomy is needed urgently because of Tracheostomy is needed urgently because of laryngeal and glottis oedema laryngeal and glottis oedema
- 23. Erysipalas Erysipalas Definition Definition spreading inflammation of the skin and spreading inflammation of the skin and subcutaneous tissues subcutaneous tissues Streptococcus pyogenes Streptococcus pyogenes. . Predisposing factors Predisposing factors Poor hygienic living conditions Poor hygienic living conditions Recurrent upper respiratory tract infections Recurrent upper respiratory tract infections Debilitating illness Debilitating illness Extremes of life Extremes of life
- 24. Develop around a scratch or abrasion Develop around a scratch or abrasion Rapid toxaemia associated with the local infection Rapid toxaemia associated with the local infection Rose-pink rash extending over the skin Rose-pink rash extending over the skin The rash has a very clear edge and considerable oedema The rash has a very clear edge and considerable oedema Following the fading of rash, a brown discolouring of Following the fading of rash, a brown discolouring of the skin remains. the skin remains. The The S. pyogenes S. pyogenes remains fully sensitive to penicillin remains fully sensitive to penicillin. .
- 25. Bacteraemia and septicaemia Bacteraemia and septicaemia
- 26. Definition of bacteraemia Definition of bacteraemia Presence of organisms in the blood which may Presence of organisms in the blood which may be transient . be transient . Definition of septicaemia Definition of septicaemia Presence of multiplying organisms & toxins in Presence of multiplying organisms & toxins in the circulation the circulation
- 27. Clinical features of septicaemia Clinical features of septicaemia source of infection Hypotension Pyrexia with rigor Hepatic involvement ( Hepatic failure) Renal involvement ( Cortical necrosis) Peripheral circulatory failure DIC MODF
- 28. Treatment Treatment Presence of septicaemia Immediate & aggressive > 3 blood cultures Broad spectrum- B-lactamase Metro Aminoglycoside Blood transfusion or plasma expander Hydrocortisone
- 29. Pyaemia Pyaemia
- 30. Definition Definition Presence of pyogenic materials Presence of pyogenic materials ( including pus ) ( including pus ) in the blood. in the blood.
- 31. Clinical features Clinical features focus of infection, abscess focus of infection, abscess fever with chills & rigor fever with chills & rigor General General constitutional symptoms constitutional symptoms Anaemia Anaemia Weight loss Weight loss GD GD
- 32. Treatment of pyaemia Treatment of pyaemia Blood Culture & Sensitivity Blood Culture & Sensitivity Appropriate antibiotics Appropriate antibiotics Aspiration / I&D of abscess Aspiration / I&D of abscess General supportive treatment General supportive treatment
- 33. Boils Boils
- 34. Definition Definition Acute staphylococcal infection of hair follicle, Acute staphylococcal infection of hair follicle, with perifolliculitis, which usually proceeds to with perifolliculitis, which usually proceeds to suppuration and central necrosis. suppuration and central necrosis. Causal organisms Causal organisms Staphylococcus aureus Staphylococcus aureus
- 35. Clinical features Clinical features Common sites Common sites back of the neck, axilla, perianal region and face back of the neck, axilla, perianal region and face Follicles of eye lashes – stye Follicles of eye lashes – stye Painful indurated swelling Painful indurated swelling After 2-3 days After 2-3 days centre is softened centre is softened Small slough is discharge with a bead of pus Small slough is discharge with a bead of pus After that majority of cases subsides After that majority of cases subsides Some subside without suppuration Some subside without suppuration
- 36. Complications Complications Cellulites Cellulites Infection of regional lymph nodes Infection of regional lymph nodes Secondary boils due to infection of Secondary boils due to infection of neighbouring hair follicle neighbouring hair follicle
- 37. Treatment Treatment To improve general health To improve general health If discharge is present If discharge is present C & S C & S Appropriate antibiotic Appropriate antibiotic When pus is visible When pus is visible Incision and drainage Incision and drainage
- 39. Definition Definition Infective gangrene of subcutaneous tissue due to Infective gangrene of subcutaneous tissue due to staphylococcus staphylococcus Incidence Incidence Uncommon before 40 Uncommon before 40 Male > female Male > female
- 40. Causal organism Causal organism Staphylococcus aureus Staphylococcus aureus Associated disease Associated disease diabetes mellitus diabetes mellitus
- 41. Clinical feature Clinical feature Common site Common site Nape of the neck where skin is coarse and ill nourish Nape of the neck where skin is coarse and ill nourish Tenderness and stiffness Tenderness and stiffness Overlying skin is red Overlying skin is red Subcutaneous tissue become painful and indurated Subcutaneous tissue become painful and indurated Later areas of softening appear Later areas of softening appear Thick pus and sloughs discharge through the skin Thick pus and sloughs discharge through the skin Sieve like appearance is pathognomonic Sieve like appearance is pathognomonic These openings coalesce to each other and form a large opening These openings coalesce to each other and form a large opening
- 42. Treatment Treatment Control diabetes Control diabetes Culture and sensitivity Culture and sensitivity Appropriate antibiotic Appropriate antibiotic Excision Excision Skin graph is required Skin graph is required
- 43. Tetanus Tetanus
- 45. Less than 100 cases per year in the UK Less than 100 cases per year in the UK More prevalent in developing countries More prevalent in developing countries Following deep or penetrating wound in Following deep or penetrating wound in relatively avascular areas relatively avascular areas
- 46. Causal organism Causal organism Clostridium tetani Clostridium tetani Gram-positive rod with terminal spores Gram-positive rod with terminal spores Drum stick appearance Drum stick appearance Strict anaerobe Strict anaerobe Produce powerful exotoxin. Produce powerful exotoxin. Exotoxin causes muscle spasms and rigidity Exotoxin causes muscle spasms and rigidity
- 47. Pathogenesis Pathogenesis Spores of Spores of Clostridium tetani Clostridium tetani live in feces, soil, dust and on live in feces, soil, dust and on instrument. instrument. The spores enter through breach in skin and mucous The spores enter through breach in skin and mucous membrane membrane Then germinate and produce exotoxin. Then germinate and produce exotoxin. This travel up peripheral nerves This travel up peripheral nerves Interferes with inhibitory synapse. Interferes with inhibitory synapse. Reduces the release of inhibitory neurotransmitters Reduces the release of inhibitory neurotransmitters Excess activity of motor neurones produces muscle Excess activity of motor neurones produces muscle spasm spasm
- 48. Prophylaxis of tetanus Prophylaxis of tetanus Prevention of high risk group Prevention of high risk group Pregnant mother Pregnant mother ATT - first dose at 28 weeks ATT - first dose at 28 weeks Second dose-6weeks later Second dose-6weeks later Third dose-6 weeks after delivery Third dose-6 weeks after delivery Infant Infant ATT 3 doses during infancy ATT 3 doses during infancy Booster dose at 5 years. Booster dose at 5 years. Farmers, labourers Farmers, labourers ATT - 3 doses( 6 weeks after first and 6 months after second) ATT - 3 doses( 6 weeks after first and 6 months after second) Booster dose for ever 5 years or at the time of injury. Booster dose for ever 5 years or at the time of injury.
- 49. Prevention at the time of injury Prevention at the time of injury Thorough wound debridement Thorough wound debridement Penicillin to kill the Penicillin to kill the Cl. tetani Cl. tetani Patient with adequate immunisation Patient with adequate immunisation Booster dose of ATT Booster dose of ATT Patient with inadequate or no immunisation Patient with inadequate or no immunisation small risk wound - ATT small risk wound - ATT High risk wound High risk wound ATT plus human antitetanus globulin ATT plus human antitetanus globulin Second and third dose of ATT at 6 weeks and 6 months interval Second and third dose of ATT at 6 weeks and 6 months interval
- 50. Clinical features Clinical features Incubation period Incubation period Time of injury to first symptom Time of injury to first symptom 7-10 days, sometimes up to years. 7-10 days, sometimes up to years. Period of onset Period of onset First symptom to first reflex spasm First symptom to first reflex spasm 5-7 days 5-7 days Prodromal symptoms Prodromal symptoms fever, malaise, headache fever, malaise, headache
- 51. Trismus (patient can not open his mouth) Trismus (patient can not open his mouth) Risus sardonicus (a grin-like posture of hypertonic Risus sardonicus (a grin-like posture of hypertonic facial muscles) facial muscles) Opisthotonus (arched body with hyperextended neck) Opisthotonus (arched body with hyperextended neck) spasms (at first may be induced by stimulus but later are spasms (at first may be induced by stimulus but later are spontaneous) spontaneous) Dysphagia and respiratory arrest Dysphagia and respiratory arrest autonomic dysfunction (arrythmias, wide fluctuation in autonomic dysfunction (arrythmias, wide fluctuation in BP) BP)
- 52. Bad prognostic signs Bad prognostic signs Short incubation period Short incubation period Rapid progression from trismus to spasms (<48 Rapid progression from trismus to spasms (<48 hours) hours) Tetanus in neonates and old age Tetanus in neonates and old age
- 53. Differential diagnosis of tetanus Differential diagnosis of tetanus
- 54. Management Management General treatment General treatment Hospitalised the patient Hospitalised the patient Isolate the patient in quiet and comfortable Isolate the patient in quiet and comfortable place with dim lighting. place with dim lighting.
- 55. Clean wounds Clean wounds Debride as necessary Debride as necessary i.v. penicillin or metronidazole for 7 days to i.v. penicillin or metronidazole for 7 days to destroy the bacteria destroy the bacteria Human tetanus immune globulin (HTIG) 500 U Human tetanus immune globulin (HTIG) 500 U i.m. to neutralise free toxin i.m. to neutralise free toxin Antitetanus toxoid to get active immunity Antitetanus toxoid to get active immunity
- 56. Control fever Control fever Analgesic for muscle pain Analgesic for muscle pain Fluid therapy for daily requirement Fluid therapy for daily requirement Care and maintenance of airway during cyanotic Care and maintenance of airway during cyanotic convulsion convulsion
- 57. Specific treatment depends on severity of disease Specific treatment depends on severity of disease Stage 1. Mild case Stage 1. Mild case Tonic rigidity alone Tonic rigidity alone Sedation Sedation Relaxation by drugs Relaxation by drugs promazine up to 200 mg. and a barbiturate or diazepan. promazine up to 200 mg. and a barbiturate or diazepan. Feeding Feeding orally +/- IV fluid orally +/- IV fluid
- 58. Stage 2. A seriously ill patient Stage 2. A seriously ill patient Dysphagia and reflex spasm. Dysphagia and reflex spasm. Sedation Sedation Feeding Feeding Nasogastric tube Nasogastric tube Total parenteral nutrition Total parenteral nutrition Tracheostomy Tracheostomy If the patients has any difficulty in breathing. If the patients has any difficulty in breathing.
- 59. Stage 3. Dangerously ill patients Stage 3. Dangerously ill patients A major cyanotic convulsion A major cyanotic convulsion Increasing sedation Increasing sedation Curarisation to maintain relaxation. Curarisation to maintain relaxation. Intermittent positive-pressure ventilation Intermittent positive-pressure ventilation Feeding Feeding Total parenteral nutrition Total parenteral nutrition IV fluid IV fluid
- 60. Intensive nursing care Intensive nursing care 2 hourly position change to prevent bedsore 2 hourly position change to prevent bedsore Indwelling urinary catheter change Indwelling urinary catheter change Mouth attendance Mouth attendance Care of tracheostomy, parenteral feeding and feeding Care of tracheostomy, parenteral feeding and feeding line line If recovery takes place, the patient can be If recovery takes place, the patient can be weaned from ventilator. weaned from ventilator.
- 63. Causal organism Causal organism Clostridial species: Clostridial species: Clostridium welchii Clostridium welchii Clostridium oedematiens Clostridium oedematiens Clostridium septicum Clostridium septicum Anaerobic, Gram-positive bacilli with spore formation Anaerobic, Gram-positive bacilli with spore formation Produce exotoxin Produce exotoxin Lecithinase, collagenase, lipase hyaluronidase, Lecithinase, collagenase, lipase hyaluronidase, deoxyribonuclease, saccrolytic enzymes deoxyribonuclease, saccrolytic enzymes
- 64. Clostridial spores Clostridial spores Widely distributed in the environment Widely distributed in the environment May enter traumatic or surgical wounds May enter traumatic or surgical wounds Contamination may occur from patients own Contamination may occur from patients own fecal flora fecal flora
- 65. Pathogenesis Pathogenesis Invasion and multiplication of organism Invasion and multiplication of organism Production of exotoxin Production of exotoxin Gangrene of muscle and gas bubble production Gangrene of muscle and gas bubble production Usually spread up and down the muscle Usually spread up and down the muscle Haemolysis, shock, ARF Haemolysis, shock, ARF
- 66. Predisposing conditions Predisposing conditions Extensively lacerated muscle or missile wound Extensively lacerated muscle or missile wound especially at buttock, thigh, axilla, retroperitoneal especially at buttock, thigh, axilla, retroperitoneal muscle muscle Open wound grossly contaminated by soil Open wound grossly contaminated by soil Lower GI surgery in diabetes Lower GI surgery in diabetes Lower limb amputation in diabetes Lower limb amputation in diabetes Abortion, puerperial sepsis Abortion, puerperial sepsis
- 67. Clinical features Clinical features History of injury or wound with extensive History of injury or wound with extensive muscle damage or soil contamination muscle damage or soil contamination Suddenly deteriorate within few hours Suddenly deteriorate within few hours Toxic and unwell Toxic and unwell Features of shock, haemolysis or renal failure Features of shock, haemolysis or renal failure
- 68. Local signs of gas gangrene Local signs of gas gangrene Myositis or myonecrosis Myositis or myonecrosis Unusual pain in the wound or limb Unusual pain in the wound or limb Heaviness of limb Heaviness of limb Tense swollen limb Tense swollen limb Mottled discolouring of overlying skin Mottled discolouring of overlying skin Stitches are under tension Stitches are under tension Thin brownish fluid discharge from the wound Thin brownish fluid discharge from the wound Gas formation with palpable crepitus Gas formation with palpable crepitus
- 69. Diagnosis Diagnosis Clinically Clinically Bacteriological Bacteriological Gram stain Gram stain Culture and sensitivity Culture and sensitivity Radiological Radiological Plain X-ray shows gas in the subcutaneous tissue and Plain X-ray shows gas in the subcutaneous tissue and fascial plains fascial plains
- 70. Differential diagnosis Differential diagnosis
- 71. Treatment Treatment Failure of recognisation results in rapid deterioration Failure of recognisation results in rapid deterioration General treatment General treatment Adequate resuscitation Adequate resuscitation Barrier nursing Barrier nursing C Pen IV 10 mega units 6 hourly with or without metronidazole C Pen IV 10 mega units 6 hourly with or without metronidazole Transfusion of blood or plasma Transfusion of blood or plasma Anti-gas gangrene serum Anti-gas gangrene serum Hyperbaric oxygen may be helpful Hyperbaric oxygen may be helpful Analgesics and sedative Analgesics and sedative
- 72. Local treatment Local treatment Debridement or amputation to remove affected tissue Debridement or amputation to remove affected tissue or limb or limb Leave the wound open Leave the wound open Delayed primary or secondary suture Delayed primary or secondary suture Rehabilitation and physiotherapy Rehabilitation and physiotherapy Exercise Exercise Prosthesis, occupational therapy, psychotherapy Prosthesis, occupational therapy, psychotherapy
- 73. Prevention Prevention Thorough wound toilet Thorough wound toilet leaving the wound open especially for wound leaving the wound open especially for wound with extensive muscle damage with extensive muscle damage Penicillin antibiotic prophylaxis Penicillin antibiotic prophylaxis contaminated wounds contaminated wounds Diabetic undergoing elective peripheral vascular Diabetic undergoing elective peripheral vascular surgery surgery
- 76. Common throughout the world Common throughout the world Significant morbidity and mortality particularly Significant morbidity and mortality particularly in Asia and Africa in Asia and Africa Causal organism Causal organism Mycobacterium tuberrculosis Mycobacterium tuberrculosis Mycobacterium bovis Mycobacterium bovis
- 77. Common site of tuberculosis infection Common site of tuberculosis infection Lung Lung GI tract and peritoneum GI tract and peritoneum Genitourinary system Genitourinary system Bone Bone Pericardium Pericardium Meningitis Meningitis
- 78. Route of infection Route of infection Pulmonary tuberculosis Pulmonary tuberculosis Air borne Air borne Intestinal tuberculosis Intestinal tuberculosis Infected milk Infected milk
- 79. Pathology of tubercle Pathology of tubercle Diagnostic for TB Diagnostic for TB Classical appearance - caseating necrosis Classical appearance - caseating necrosis Tubercle Tubercle central caseaous necrosis central caseaous necrosis surrounded by lymphocytes, giant cells and surrounded by lymphocytes, giant cells and epitheloid macrophages epitheloid macrophages Organisms may be identified within the Organisms may be identified within the macrophages macrophages
- 82. Common throughout the world Common throughout the world Significant morbidity and mortality particularly Significant morbidity and mortality particularly in Asia and Africa in Asia and Africa Causal organism Causal organism Mycobacterium tuberrculosis Mycobacterium tuberrculosis Mycobacterium bovis Mycobacterium bovis
- 83. Common site of tuberculosis infection Common site of tuberculosis infection Lung Lung GI tract and peritoneum GI tract and peritoneum Genitourinary system Genitourinary system Bone Bone Pericardium Pericardium Meningitis Meningitis
- 84. Route of infection Route of infection Pulmonary tuberculosis Pulmonary tuberculosis Air borne Air borne Intestinal tuberculosis Intestinal tuberculosis Infected milk Infected milk
- 85. Pathology of tubercle Pathology of tubercle Diagnostic for TB Diagnostic for TB Classical appearance - caseating necrosis Classical appearance - caseating necrosis Tubercle Tubercle central caseaous necrosis central caseaous necrosis surrounded by lymphocytes, giant cells and surrounded by lymphocytes, giant cells and epitheloid macrophages epitheloid macrophages Organisms may be identified within the Organisms may be identified within the macrophages macrophages
- 86. Primary tuberculosis Primary tuberculosis Initial infection with Initial infection with Mycobacterium tuberculosis Mycobacterium tuberculosis Childhood Childhood Usually - pulmonary infection Usually - pulmonary infection Primary complex Primary complex Sub pleural Gohn focus Sub pleural Gohn focus Draining nodes are infected Draining nodes are infected
- 89. Common throughout the world Common throughout the world Significant morbidity and mortality particularly Significant morbidity and mortality particularly in Asia and Africa in Asia and Africa Causal organism Causal organism Mycobacterium tuberrculosis Mycobacterium tuberrculosis Mycobacterium bovis Mycobacterium bovis
- 90. Common site of tuberculosis infection Common site of tuberculosis infection Lung Lung GI tract and peritoneum GI tract and peritoneum Genitourinary system Genitourinary system Bone Bone Pericardium Pericardium Meningitis Meningitis
- 91. Route of infection Route of infection Pulmonary tuberculosis Pulmonary tuberculosis Air borne Air borne Intestinal tuberculosis Intestinal tuberculosis Infected milk Infected milk
- 92. Pathology of tubercle Pathology of tubercle Diagnostic for TB Diagnostic for TB Classical appearance - caseating necrosis Classical appearance - caseating necrosis Tubercle Tubercle central caseaous necrosis central caseaous necrosis surrounded by lymphocytes, giant cells and surrounded by lymphocytes, giant cells and epitheloid macrophages epitheloid macrophages Organisms may be identified within the Organisms may be identified within the macrophages macrophages
- 93. Primary tuberculosis Primary tuberculosis Initial infection with Initial infection with Mycobacterium tuberculosis Mycobacterium tuberculosis Childhood Childhood Usually - pulmonary infection Usually - pulmonary infection Primary complex Primary complex Sub pleural Gohn focus Sub pleural Gohn focus Draining nodes are infected Draining nodes are infected
- 94. Early spread of bacilli Early spread of bacilli Immunity rapidly develops, and infection become Immunity rapidly develops, and infection become quiescent at all sites quiescent at all sites Complications Complications Haematogenous spread Haematogenous spread miliary TB affecting lungs, bones, joints, meninges miliary TB affecting lungs, bones, joints, meninges Direct pulmonary spread Direct pulmonary spread TB bronchopneumonia TB bronchopneumonia Commonest non-pulmonary Commonest non-pulmonary primary primary infection infection GI, most commonly affecting the ileo-caecal junction and GI, most commonly affecting the ileo-caecal junction and associated lymph nodes associated lymph nodes
- 95. Post-primary tuberculosis Post-primary tuberculosis Adolescence or adult life Adolescence or adult life Due to reactivation of infection or repeated Due to reactivation of infection or repeated exposure exposure Reactivation may be associated with Reactivation may be associated with immunosupression immunosupression HIV infection HIV infection Diabetes Diabetes Steroids Steroids
- 96. Pulmonary infection Pulmonary infection 70% of cases of post-primary TB 70% of cases of post-primary TB Apices of upper or lower lobes Apices of upper or lower lobes Cavitation of infection into bronchial tree results Cavitation of infection into bronchial tree results in 'open TB' in 'open TB' Infection of lymph glands Infection of lymph glands Discrete, firm and painless lymphadenopathy Discrete, firm and painless lymphadenopathy Confluence of infected glands Confluence of infected glands 'cold' abscess 'cold' abscess
- 97. Clinical features Clinical features Nonspecific symptoms Nonspecific symptoms Weight loss Weight loss Anorexia Anorexia Night sweats Night sweats Pulmonary TB Pulmonary TB Cough, sputum, haemoptysis Cough, sputum, haemoptysis Pneumonia pleural effusion Pneumonia pleural effusion Chest pain Chest pain
- 98. Miliary TB Miliary TB Non-specific Non-specific Genitourinary TB Genitourinary TB Dysuria, haematuria, frequency Dysuria, haematuria, frequency Sterile pyuria Sterile pyuria TB bone TB bone Usually affect spine Usually affect spine adjacent vertebrae collapse adjacent vertebrae collapse Associated with paravertebral abscess Associated with paravertebral abscess
- 99. TB peritonitis TB peritonitis Abdominal pain Abdominal pain GI upset GI upset TB pericarditis TB pericarditis Effusion Effusion Tamponade Tamponade Constrictive pericarditis Constrictive pericarditis TB meningitis TB meningitis
- 100. Investigations Investigations Microbiology Microbiology Sputum for AFB Sputum for AFB Microscopy Microscopy Ziehl-Neelsen stain Ziehl-Neelsen stain appear as red acid-fast bacilli appear as red acid-fast bacilli Culture Culture Difficult to culture Difficult to culture Lowenstein-Jensen method Lowenstein-Jensen method
- 101. Radiology Radiology CXR CXR calciication calciication Cavitation Cavitation X-rays of other affected areas X-rays of other affected areas Bone Bone spine spine
- 102. Immunological test Immunological test Skin tests Skin tests Delayed hypersensitivity reaction Delayed hypersensitivity reaction Mantoux and Heaf test Mantoux and Heaf test Mantoux test Mantoux test i.d. inj. of purified protein derivative i.d. inj. of purified protein derivative papule of >5mm dia. at 72 hours papule of >5mm dia. at 72 hours Heaf test Heaf test A gun is used to produce multiple punctures A gun is used to produce multiple punctures More than 4 papules at puncture sites at 72 hours More than 4 papules at puncture sites at 72 hours Positive skin test Positive skin test Indication of active infection or previousBCG vaccination Indication of active infection or previousBCG vaccination
- 103. Treatment Treatment Stress the importance of compliance Stress the importance of compliance Assessment before treatment Assessment before treatment liver and kidney function liver and kidney function Test colour vision if treated with ethanbutol Test colour vision if treated with ethanbutol First line chemotherapeutic agents First line chemotherapeutic agents Rifampicin, isoniazid and ethanbutol Rifampicin, isoniazid and ethanbutol Triple therapy for the first 2 months Triple therapy for the first 2 months Rifapincin and isoniazid are usually continued for further 7 Rifapincin and isoniazid are usually continued for further 7 months months Less than 5% are resistant to first line treatment Less than 5% are resistant to first line treatment
- 104. Sepsis, asepsis & antisepsis
- 105. Definition Definition Sepsis Sepsis Systemic manifestation of a documented Systemic manifestation of a documented infection infection Wound sepsis Wound sepsis Generally known as the wound infection Generally known as the wound infection Resulting from the bacterial contamination Resulting from the bacterial contamination
- 106. Asepsis Asepsis Procedure to reduce the risk of bacterial contamination Procedure to reduce the risk of bacterial contamination Usually involves Usually involves The use of sterile instruments The use of sterile instruments The use of a gloved no touch technique The use of a gloved no touch technique Antisepsis Antisepsis removal of transient microorganisms from the skin and removal of transient microorganisms from the skin and a reduction in the resident flora a reduction in the resident flora
- 107. Definition in sepsis Definition in sepsis Systemic inflammatory response syndrome Systemic inflammatory response syndrome (SIRS); two of: (SIRS); two of: Hyperthermia (>38 C) or hypothermia (<36 C) Hyperthermia (>38 C) or hypothermia (<36 C) tachycardia (>90/min. no beta blocker) or tachycardia (>90/min. no beta blocker) or tachypnoea (>20/min.) tachypnoea (>20/min.) white cell count >12*10 /litre or <4*10 / litre white cell count >12*10 /litre or <4*10 / litre Sepsis is SIRS with a documented infection Sepsis is SIRS with a documented infection Severe sepsis or sepsis syndrome is sepsis with Severe sepsis or sepsis syndrome is sepsis with evidence of one or more organ evidence of one or more organ failure failure
- 108. Bacteria involved in wound infection Bacteria involved in wound infection Staphylococcus Staphylococcus Streptococcus Streptococcus Clostridial organisms Clostridial organisms Aerobic Gram-negative bacilli (AGNB) Aerobic Gram-negative bacilli (AGNB) Bacteroides Bacteroides
- 109. Staphylococcus Staphylococcus Gram positive cocci, Gram positive cocci, and form clumps and form clumps Staphylococcus aureus Staphylococcus aureus Most important pathogen Most important pathogen It can cause exogenous suppuration in wounds (and It can cause exogenous suppuration in wounds (and implanted prosthesis) and MRSA. implanted prosthesis) and MRSA. Staphylococcus epidemidis Staphylococcus epidemidis Regarded as a commensal Regarded as a commensal Major threat in prosthetic surgery Major threat in prosthetic surgery
- 110. Streptococcus Streptococcus Gram-positive, cocci and in the form of chains Gram-positive, cocci and in the form of chains beta haemolytic streptococcus beta haemolytic streptococcus ( (Streptococcus pyogenes) Streptococcus pyogenes) Can cause cellulitis Can cause cellulitis Streptococcus faecalis Streptococcus faecalis and peptostrptococcus and peptostrptococcus wound infection after large bowel surgery. wound infection after large bowel surgery. alpha haemolytic alpha haemolytic streptococcus viridans streptococcus viridans not related to wound infection. not related to wound infection.
- 111. Clostridial organisms Clostridial organisms Gram positive, obligate anaerobes and spore Gram positive, obligate anaerobes and spore forming forming Clostridium pefringens Clostridium pefringens is the cause of gas gangrene. is the cause of gas gangrene. Clostridium tetani Clostridium tetani cause tetanus cause tetanus Clostridium difficile Clostridium difficile is the cause of is the cause of pseudomembranous colitis pseudomembranous colitis
- 112. Aerobic Gram-negative bacilli (AGNB) Aerobic Gram-negative bacilli (AGNB) Act synergy with Act synergy with Bacteroides Bacteroides to cause wound infections to cause wound infections after bowel operations. after bowel operations. Bacteroides Bacteroides Nonspore bearing Nonspore bearing Strict anaerobes Strict anaerobes Colonise the large bowel, vagina and oropharynx. Colonise the large bowel, vagina and oropharynx. Bacteoides fragilis Bacteoides fragilis acts in synergy with AGNB to cause wound infection after acts in synergy with AGNB to cause wound infection after colorectal or gynaecological surgery colorectal or gynaecological surgery. .
- 113. Clinical features of sepsis Clinical features of sepsis Superficial surgical site infection (SSSI) is an Superficial surgical site infection (SSSI) is an infected wound. infected wound. SIRS (systemic inflammatory response SIRS (systemic inflammatory response syndrome) is the body's systemic response to an syndrome) is the body's systemic response to an infected wound. infected wound. MODS is the effect that the infection has on the MODS is the effect that the infection has on the whole body. whole body.
- 114. Treatment of surgical wound Treatment of surgical wound infections infections Antibiotic Antibiotic Drainage of pus and debridement if necessary Drainage of pus and debridement if necessary Pus for culture and sensitivity Pus for culture and sensitivity
- 115. Antibiotics used in treatment and Antibiotics used in treatment and prophylaxis of wound infection prophylaxis of wound infection Penicillin Penicillin Cephalosporin Cephalosporin Aminoglycosides Aminoglycosides Broad spectrum antibiotics Broad spectrum antibiotics Erythromycin Erythromycin Clindamycin Clindamycin Sulphonamides Sulphonamides Metronidazole Metronidazole
- 116. Principles of antimicrobial treatment Principles of antimicrobial treatment Selection of antibiotics Selection of antibiotics The following sequence of events usually occurs: The following sequence of events usually occurs: A decision is made on clinical grounds that an A decision is made on clinical grounds that an infection exists. infection exists. Based on signs, symptoms and clinical Based on signs, symptoms and clinical experience, guess is made at the likely infecting experience, guess is made at the likely infecting organism.( a organism.( a best-guess policy best-guess policy ) ) The appropriate specimens are taken for The appropriate specimens are taken for microbiological examination, i.e. culture and microbiological examination, i.e. culture and sensitivity testing. sensitivity testing.
- 117. The cheapest and most effective drug or The cheapest and most effective drug or combination of drugs effective against the combination of drugs effective against the suspected organism is given. suspected organism is given. the use of a narrow-spectrum antibiotic to treat the use of a narrow-spectrum antibiotic to treat a known sensitive infection. a known sensitive infection. the use of broad-spectrum antibiotic combination the use of broad-spectrum antibiotic combination - where the organism is not known - where the organism is not known - where it is suspected that the organism may - where it is suspected that the organism may be be two two or more, usually gut derived or more, usually gut derived bacteria bacteria responsible for the infection responsible for the infection acting in synergy. acting in synergy.
- 118. The clinical response to treatment is monitored. The clinical response to treatment is monitored. The antibiotic treatment is altered , if necessary, in The antibiotic treatment is altered , if necessary, in response to laboratory reports of culture and sensitivity. response to laboratory reports of culture and sensitivity.
- 119. Route of administration Route of administration i.v. i.v. Severe infections Severe infections Seriously ill patients. Seriously ill patients. Oral Oral When the patients improves When the patients improves GI tract is functioning satisfactory GI tract is functioning satisfactory
- 120. Duration of therapy Duration of therapy Depends on the Depends on the Individual’s response and laboratory tests. Individual’s response and laboratory tests. Clinical cure Clinical cure Microbiological data Microbiological data Dosage Dosage Modified in renal and liver disease. .
- 121. Possible causes of poor response of Possible causes of poor response of the infection to an appropriate the infection to an appropriate antibiotics: antibiotics: Presence of pus , necrotic tissue ,foreign bodies Presence of pus , necrotic tissue ,foreign bodies Failure of the drug to reach the tissues in Failure of the drug to reach the tissues in therapeutic concentrations therapeutic concentrations Organisms isolated is not the one responsible Organisms isolated is not the one responsible for infection for infection After prolonged antibiotic therapy, new After prolonged antibiotic therapy, new organisms develop organisms develop Inadequate dosage or in appropriate route of Inadequate dosage or in appropriate route of administration administration
- 122. Prophylactic antibiotics Prophylactic antibiotics Antibiotics giving in perioperative period Antibiotics giving in perioperative period Aim Aim to achieve therapeutic levels at the time of surgery. to achieve therapeutic levels at the time of surgery. to reduce the risk of wound infection, sepicaemia to reduce the risk of wound infection, sepicaemia and bacteraemia and bacteraemia
- 123. Indications for prophylactic Indications for prophylactic antibiotics antibiotics Immunosuppressed patients Immunosuppressed patients Diabetes, steroids Diabetes, steroids Implantation of foreign bodies Implantation of foreign bodies Organ transplantation Organ transplantation Patient's with pre-existing cardiac disease Patient's with pre-existing cardiac disease Clean contaminated wounds. Clean contaminated wounds. Amputations especially for ischaemia or crush injuries Amputations especially for ischaemia or crush injuries Compound fractures and penetrating wounds Compound fractures and penetrating wounds
- 124. One dose is given preoperatively One dose is given preoperatively orally if under LA (1 hour preoperatively) orally if under LA (1 hour preoperatively) i.v. if under GA ( at the time of induction of i.v. if under GA ( at the time of induction of anaesthesia). anaesthesia).
- 125. Prophylaxis of surgical wound Prophylaxis of surgical wound infection infection Preoperative preparation of the patients Preoperative preparation of the patients Treatment of preexisting infections Treatment of preexisting infections Improved general condition of the patient Improved general condition of the patient Skin preparation Skin preparation Mechanical bowel preparation Mechanical bowel preparation Antibiotic prophylaxis Antibiotic prophylaxis
- 126. Operating theatre and instruments Operating theatre and instruments Sterilization of instruments, sutures etc. Sterilization of instruments, sutures etc. Siting and design of operating theatre Siting and design of operating theatre Air filtration and positive pressure ventilation Air filtration and positive pressure ventilation of operating theatre of operating theatre
- 127. Opeartion Opeartion Preparation of surgeon and staff before Preparation of surgeon and staff before operation operation Exclusion of staff with infection Exclusion of staff with infection Good surgical technique Good surgical technique
- 128. Postopeartive management Postopeartive management Improved patients general condition Improved patients general condition Prevention of cross infection Prevention of cross infection Dressing changes Dressing changes Respiratory care Respiratory care Urinary care Urinary care Catheter and cannnula care Catheter and cannnula care
- 129. Asepsis and antisepsis Asepsis and antisepsis
- 130. History History 1847-Semmelweis identifies surgeons hands as 1847-Semmelweis identifies surgeons hands as route of spread of puerperal infection route of spread of puerperal infection 1865-Lister introduces hand and wound asepsis 1865-Lister introduces hand and wound asepsis with the use of carbolic acid with the use of carbolic acid 1880-von Bergmann invents the autoclave 1880-von Bergmann invents the autoclave
- 131. Asepsis and antisepsis Asepsis and antisepsis Asepsis Asepsis Asepsis is procedure to reduce the risk of Asepsis is procedure to reduce the risk of bacterial contamination bacterial contamination use of sterile instruments use of sterile instruments use of a gloved no touch technique use of a gloved no touch technique Antisepsis Antisepsis Antisepsis is the removal of transient Antisepsis is the removal of transient microorganisms from the skin and a reduction in microorganisms from the skin and a reduction in the resident flora the resident flora
- 132. Sterilisation and disinfection Sterilisation and disinfection Sterilisation Sterilisation Complete destruction or removal of all viable Complete destruction or removal of all viable microoragasms including spores and viruses microoragasms including spores and viruses Disinfection Disinfection a reduction in the number of viable a reduction in the number of viable microorganisms but will not necessarily microorganisms but will not necessarily inactivate viruses and bacterial spores inactivate viruses and bacterial spores
- 133. Sterilisation Sterilisation Methods of sterilisation Methods of sterilisation Autoclaves Autoclaves Hot air ovens Hot air ovens Ethylene oxide Ethylene oxide Low-temperature steam and formaldehyde Low-temperature steam and formaldehyde Sterilisation by irradiation Sterilisation by irradiation Sporicidal chemicals Sporicidal chemicals
- 134. Autoclaves Autoclaves Sterilised by steam under pressure Sterilised by steam under pressure Highly effective and inexpensive Highly effective and inexpensive Unsuitable for heat-sensitive objects Unsuitable for heat-sensitive objects Effective against Effective against vegetative bacteria, including tuberculosis , vegetative bacteria, including tuberculosis , viruses such as hepatitis B, hepatitis C and HIV viruses such as hepatitis B, hepatitis C and HIV heat resistant spores, including heat resistant spores, including Clostridium tetani Clostridium tetani and and Clostridium perfringes Clostridium perfringes
- 135. 121 C (15 lb/in 2) for a hold time of 15 minutes. 121 C (15 lb/in 2) for a hold time of 15 minutes. 134 C (30 lb/in 2) for a hold time of 3 minutes 134 C (30 lb/in 2) for a hold time of 3 minutes Prepacked materials and instruments are Prepacked materials and instruments are processed through a porous load autoclave processed through a porous load autoclave which incorporates a prevacuum cycle necessary which incorporates a prevacuum cycle necessary to extract air to extract air Check performance by colour changes on Check performance by colour changes on indicator tape indicator tape
- 136. Hot air ovens Hot air ovens Inefficient compared to autoclaves Inefficient compared to autoclaves Lack of corosion (used for fine cutting edge) Lack of corosion (used for fine cutting edge) Ability to treat solid, nonaquous liquids, grease/ Ability to treat solid, nonaquous liquids, grease/ ointments and closed container ointments and closed container Cannot be used for rubber, plastics and Cannot be used for rubber, plastics and intravenous fluids intravenous fluids Requires temperatures of 160 Requires temperatures of 160→C for 2 hours or →C for 2 hours or 180 →C for 30 min 180 →C for 30 min
- 137. Ethylene oxide Ethylene oxide Highly-penetrative and noncorrosive Highly-penetrative and noncorrosive Flammable, toxic and expensive Flammable, toxic and expensive Used for heat-sensitive materials including Used for heat-sensitive materials including electrical equipment electrical equipment Active against bacteria, spores and viruses Active against bacteria, spores and viruses Leaves toxic residue on sterilised items Leaves toxic residue on sterilised items Not recommended for ventilator Not recommended for ventilator
- 138. Low-temperature steam and Low-temperature steam and formaldehyde formaldehyde Combination of dried saturated steam and Combination of dried saturated steam and formaldehyde formaldehyde Sterilisation is achieved at a low temperature (73 Sterilisation is achieved at a low temperature (73 C) C) Suitable for heat-sensitive materials and plastic Suitable for heat-sensitive materials and plastic components components Not recommended for sealed oily items or those Not recommended for sealed oily items or those with retained air with retained air May cause hypersensitivity to the users May cause hypersensitivity to the users
- 139. Radiation Radiation Gamma rays or accelerated electrons Gamma rays or accelerated electrons Appropriate for sterilisation of large batches of Appropriate for sterilisation of large batches of similar products similar products Syringe Syringe Catheters Catheters Intravenous cannulas Intravenous cannulas Radiation dose in excess of 25kGy Radiation dose in excess of 25kGy
- 140. Sporicidal chemicals Sporicidal chemicals Often used as disinfectants but can also sterilise Often used as disinfectants but can also sterilise instruments instruments Inexpensive Inexpensive Suitable for heat-sensitive items Suitable for heat-sensitive items Toxic and irritants Toxic and irritants 2% Gluteraldehyde 2% Gluteraldehyde Most bacteria and viruses killed within 10 minutes Most bacteria and viruses killed within 10 minutes Spores can survive several hours Spores can survive several hours
- 141. Disinfection Disinfection Methods of disinfections Methods of disinfections Low-temperature steam Low-temperature steam Boiling water Boiling water Chemical disinfectants Chemical disinfectants
- 142. Low-temperature steam Low-temperature steam Effect most bacteria and viruses Effect most bacteria and viruses Dry saturated steam at 73 Dry saturated steam at 73 C for a period of 20 C for a period of 20 minutes at a pressure below atmosphere minutes at a pressure below atmosphere Useful process for dirty returns from the Useful process for dirty returns from the operating theatre or clinics which may be operating theatre or clinics which may be contaminated with protein from bodily contaminated with protein from bodily secretions and microorganisms secretions and microorganisms
- 143. Boiling water Boiling water Soft water at 100 C at normal pressure for 5 Soft water at 100 C at normal pressure for 5 minutes minutes Instruments must be thoroughly cleaned before Instruments must be thoroughly cleaned before being utilised being utilised
- 144. Chemical disinfectants Chemical disinfectants Destroys microorganisms by chemical or Destroys microorganisms by chemical or physicochemical means physicochemical means Different organisms vary in their sensitivity Different organisms vary in their sensitivity Gram-positive - highly sensitive Gram-positive - highly sensitive Gram-negative - relatively resistant Gram-negative - relatively resistant Clostridial & mycobacterial species - very resistant Clostridial & mycobacterial species - very resistant Slow viruses - highly resistant Slow viruses - highly resistant
- 145. suitable for heat-sensitive items suitable for heat-sensitive items Less effective than heat Less effective than heat Chemicals used include: Chemicals used include: Clear soluble phenolics Clear soluble phenolics Hypochlorites Hypochlorites Alcohols Alcohols Quaternary ammonium compounds Quaternary ammonium compounds
- 146. Safeguards for equipment during Safeguards for equipment during sterilisation sterilisation Thorough cleaning Thorough cleaning Appropriate packing in order to avoid reduced Appropriate packing in order to avoid reduced penetration of the active agent penetration of the active agent Arrangement of articles so that all surfaces are directly Arrangement of articles so that all surfaces are directly exposed to the agent exposed to the agent The use of chemical indicators routinely The use of chemical indicators routinely The interval monitoring of sterilisation process with The interval monitoring of sterilisation process with chemical, thermal, and sometimes, biological indicators chemical, thermal, and sometimes, biological indicators A careful maintenance plan for all sterilisation A careful maintenance plan for all sterilisation processes processes
- 148. Surgical infections arise either in the community Surgical infections arise either in the community or in the hospital. or in the hospital. Hospital infection (nosocomial infections) Hospital infection (nosocomial infections) originate in the operating theatre, and in the originate in the operating theatre, and in the wards. wards.
- 149. Nosocomial infections arising during operations Nosocomial infections arising during operations Infections of surgical wounds Infections of surgical wounds Ward-acquired nosocomial infections Ward-acquired nosocomial infections Postoperative pneumonia Postoperative pneumonia Urinary tract infections Urinary tract infections Infection associated with cannulas Infection associated with cannulas Nosocomial peritonitis Nosocomial peritonitis Secondary infections of wounds Secondary infections of wounds
- 150. Community-acquired infections Community-acquired infections Lacerations Lacerations Acute infections of the digestive tract Acute infections of the digestive tract Acute infections complicating arterial or venous Acute infections complicating arterial or venous insufficiency insufficiency
- 151. Definitions Definitions Wound infection Wound infection The invasion of organisms through tissues following a The invasion of organisms through tissues following a breakdown of local and systemic host defences. breakdown of local and systemic host defences. Major wound infection Major wound infection A wound which discharge pus and need a secondary A wound which discharge pus and need a secondary procedure or secondary drainage. procedure or secondary drainage. There may be systemic signs of tachycardia, pyrexia and There may be systemic signs of tachycardia, pyrexia and a raised white count (SIRS) a raised white count (SIRS)
- 152. Minor wound infection Minor wound infection It may discharge pus or infected serous fluid but should It may discharge pus or infected serous fluid but should not be associated with excessive discomfort, systemic not be associated with excessive discomfort, systemic signs or delay in return home. signs or delay in return home.
- 153. Bacteria involved in wound infection Bacteria involved in wound infection Stapholoccus Stapholoccus Streptoccus Streptoccus Clostridial organisms Clostridial organisms Aerobic Gram-negative bacilli (AGNB) Aerobic Gram-negative bacilli (AGNB) Bacteroides Bacteroides
- 154. Source of wound contamination Source of wound contamination Direct inoculation Direct inoculation Patients residual flora or skin contamination Patients residual flora or skin contamination Surgeon’s hand Surgeon’s hand Contaminated instruments or dressing Contaminated instruments or dressing Contaminated procedures Contaminated procedures Drains, catheters or intravenous lines Drains, catheters or intravenous lines Shared facilities (Toilet, Basin, Tower)
- 155. Air borne contamination Air borne contamination Skin and clothing of staff and patients Skin and clothing of staff and patients Air flow in operating theatre and wards Air flow in operating theatre and wards Transmissible respiratory tract infection Wound dressing Bed Making Floor polishing Toilet flushing
- 156. Haematogenous spread Intravenous lines Sepsis at other anatomical sites Skin penetrating injury
- 157. Bacteria are normally prevented from causing Bacteria are normally prevented from causing infection in tissue by: infection in tissue by: mechanical barrier (intact epithelial surfaces) mechanical barrier (intact epithelial surfaces) chemical (low gastric pH) chemical (low gastric pH) humoral (antibodies, complement and opsonins) humoral (antibodies, complement and opsonins) cellular (phagocytic cells, macrophages) cellular (phagocytic cells, macrophages)
- 158. Risk factors for wound infection Risk factors for wound infection General factors General factors Age, obesity Age, obesity malnutrition malnutrition metabolic disease (diabetes, jaundice, uraemia) metabolic disease (diabetes, jaundice, uraemia) immunosuppression (cancer, AIDS, steroids, immunosuppression (cancer, AIDS, steroids, chemotherapy, radiotherapy) chemotherapy, radiotherapy)
- 159. Local factors Local factors colonisation and transmigration in the GI tract colonisation and transmigration in the GI tract poor perfusion (systemic shock, local ischaemia) poor perfusion (systemic shock, local ischaemia) foreign body material foreign body material poor surgical technique (dead space, haematoma) poor surgical technique (dead space, haematoma) Microbiological factor Microbiological factor Type and virulence of organism Type and virulence of organism size of bacterial innoculum size of bacterial innoculum Antibiotic resistance Antibiotic resistance
- 160. Decisive period Decisive period The first 4 hour after a breach in an epithelial The first 4 hour after a breach in an epithelial surface surface During this period bacterial colonisation and During this period bacterial colonisation and established infection can begin. established infection can begin. Due to delay before mobilisation of host Due to delay before mobilisation of host defences through acute inflammatory, humoral defences through acute inflammatory, humoral and cellular processes. and cellular processes.
- 161. Classification of wounds Classification of wounds Surgical wounds may be classified by their Surgical wounds may be classified by their potential for infection potential for infection Clean wound Clean wound Clean, contaminated wound Clean, contaminated wound Contaminated wound Contaminated wound
- 162. Clean wound Clean wound Operation under sterile conditions where the GI Operation under sterile conditions where the GI tract, GU tract and respiratory tract are not tract, GU tract and respiratory tract are not breached breached. . The risk of postoperative wound infection The risk of postoperative wound infection is is less than 5%. less than 5%.
- 163. Clean contaminated Clean contaminated Operations performed under sterile conditions Operations performed under sterile conditions where the GI tract, GU tract and respiratory tract where the GI tract, GU tract and respiratory tract are opened with minimal contamination. are opened with minimal contamination. The risk of postoperative wound infection is about The risk of postoperative wound infection is about 10%. 10%.
- 164. Contaminated wound- Contaminated wound- Operation performed where contamination is Operation performed where contamination is inevitable. inevitable. The risk of postoperative wound infection is greater The risk of postoperative wound infection is greater than 50%. than 50%.
- 165. Prophylaxis of surgical wound Prophylaxis of surgical wound infection infection Preoperative preparation of the patients Preoperative preparation of the patients Treatment of preexisting infections Treatment of preexisting infections Improved general condition of the patient Improved general condition of the patient Skin preparation Skin preparation Mechanical bowel preparation Mechanical bowel preparation Antibiotic prophylaxis Antibiotic prophylaxis
- 166. Operating theatre and instruments Operating theatre and instruments Sterilization of instruments, sutures etc. Sterilization of instruments, sutures etc. Siting and design of operating theatre Siting and design of operating theatre Air filtration and positive pressure ventilation Air filtration and positive pressure ventilation of operating theatre of operating theatre
- 167. Opeartion Opeartion Preparation of surgeon and staff before Preparation of surgeon and staff before operation operation Exclusion of staff with infection Exclusion of staff with infection Good surgical technique Good surgical technique
- 168. Postopeartive management Postopeartive management Improved patients general condition Improved patients general condition Prevention of cross infection Prevention of cross infection Dressing changes Dressing changes Respiratory care Respiratory care Urinary care Urinary care Care of catheters and cannulas Care of catheters and cannulas
- 169. Prevention Prevention Direct inoculation Hand Washing Antiseptics & Disinfectants Gloves No-touch technique (Dressing) Disposable instruments Adequate staff and trained personnel Separate utensils
- 170. Air borne contamination Good ventilation Good sun light Adequate interspace Avoidance of generation of air borne particles Wet mopping Changing of bed sheet, pillow sheet, curtains
- 171. Air born contamination OT- Design two corridor system Temperature-28’ C Humidity- 55% Air filtration, laminar air flow & positive pressure ventilation, Disposable anesthetic, equipments e.g. ET tube OT Schedule for transmissible Disease
- 172. Strict food hygiene Good easily cleaned equipment Safe kitchen practice
- 173. Inoculation Vaccination (Hepatitis B) Universal precaution Postexposure prophylaxis Postexposure prophylaxis
- 174. Management of outbreak Management of outbreak E.g. tetanus, MRSA, gas gangrene, high wound infection rate compared with standard Prevention is the best policy Multidisciplinary approach Notification of it
- 175. Find out organism & sensitivity pattern Isolation of Patients Find out source of infection Treat patient and source of infection Declare the control of outbreak Preventive measure for further outbreak
- 176. AIDS
- 177. Causal organism Human immunodeficiency virus type (HIV-1) Slow virus (lentovirus) family of retrovirus. RNA viruses Cell-surfaced protein (gp 120) Recognises and binds to receptor on several types of human cells. HIV binds to the CD4+ lymphocytes (helper T- lymphocyte).
- 178. Modes of transmission By transfer of infected blood. High risk group: Homosexuals Heroin addicts Haemophiliacs
- 179. Effect of immune dysfunction The effect immune dysfunction correlates with the loss of CD4+ helper T cells. Functional impairment of CD4+ lymphocytes results in Disorders of antibody production Delayed hypersensitivity Delayed macrophage function.
- 180. This results in: Vulnerability to many opportunistic infections, Increased risk of cancer development and Malnutrition due to a reduction in nutrient absorption and metabolism.
- 181. Natural history Group I Acute infection (seroconversion illness) Group II Asymptomatic infection Group III Persistent generalised lymphadenopathy Group IV AIDS ( sub group A – E )
- 182. Presentation to surgeon I. HIV-positive patients may develop any of the diseases These are normally managed in the same way as in the non- HIV patients, Taking special precautions to prevent cross-infection of HIV disease II. Some specific conditions which are associated with the HIV disease syndrome and which occasionally require surgical intervention. Management of colorectal and anal disorder Lymph node biopsy Provision of chronic venous access
- 183. Anal disease Warts Sexually transmitted. Treatment - local excision or destruction (diathermy or laser) Can results in intraepithelial neoplasia. (AIN)
- 184. Perianal sepsis Varieties of anal fistula can develop The combination of local anal trauma with reduced immunity results in an increased risk of perianal sepsis. In those patients who do not have a low CD4+ lymphocyte count of less than 100, conventional management of perianal sepsis is appropriate. For patients with severe reduction in CD4+ count, a more conservative approach to control sepsis is more appropriate.
- 185. Anorectal ulceration Ulcer may occur in any part of the anal canal or lower rectum May be due to herpes simplex virus infection. Treatment for herpes simplex virus - acyclovir Excision of the ulcerated area with gentle anal stretch can be helpful.
- 186. Anal neoplasia The commonest neoplasms are : squamous carcinoma of the anal canal Kaposi's sarcoma involving the anal canal perirectal or perianal non-Hodgkin's lymphoma.
- 187. Faecal incontinence The association of weakened internal anal sphincter with some degree of infective proctitis can produce minor feacal incontinence. .
- 188. Appendicitis This presents as in the normal population. Appendicectomy should be carried out and the postoperative course is similar to the non-HIV patient.
- 189. Infective colitis Arises from infection with cytomegalovirus and a variety of other organisms. Severe bloody diarrhoea Toxic mega colon Colonic perforation.
- 190. Mycobacterium avium intracellulare infection Generalised symptoms are more prominent with vague abdominal pain ,fever and marrow suppression. Diagnosis - marrow aspirate or needle biopsy of enlarged lymph nodes. Laparotomy is better avoided if possible.
- 191. Non-Hodgkin's lymphoma Diagnostic laparotomy to obtain lymph node biopsy should be avoided. Occasionally, acute abdominal symptoms develop due to small bowel perforation at the site of tumour necrosis. Emergency laparotomy in this situation has been disappointing.
- 192. Lymphoma Lymphomatous swellings can occur Major surgical biopsy is unhelpful. Occasionally, biopsy is helpful to differentiate whether the lymph node enlargement is due to lymphoma or to infection.
- 193. Cholangitis The aetiology is not clearly established thought inflammation has an infective basis, perhaps cytomegalovirus. ERCP reveals changes which are similar to sclerosing cholangitis. Surgical treatment is not required.
- 194. Splenectomy Splenectomy is occasionally indicated to correct an HIV related form of autoimmune thrombocytopenia.
- 195. Risk of transmission of the disease from patients to surgeon The surgeon is regularly exposed to blood, which is the most infective medium for HIV transmission. The extent of the risk to the surgeon depends on: The prevalence of HIV in the patient population The number of procedures carried out by the surgeon The length of period of risk. Mode of transmission Skin perforation with a hollow needle containing HIV- infected blood. Extensive splashing of mucous membranes and skin.
- 196. Risk of transmission of disease from surgeon to patient No reported case of a patient undergoing a general surgical procedure acquiring HIV infection from the surgeon. Patients cross infection may also occured from an HIV-positive to an HIV-negative patient undergoing a minor surgical procedure on the same operating list.
- 197. Prevention of Infection Prevention of Infection UNIVERSAL PRECAUTIONS TO PREVENT UNIVERSAL PRECAUTIONS TO PREVENT TRANSMISSION OF HIV TRANSMISSION OF HIV Precautions in handling blood and other body fluid Precautions in handling blood and other body fluid Should wear gloves for all contact with blood or body Should wear gloves for all contact with blood or body fluids. fluids. Hands should be washed immediately after removal of Hands should be washed immediately after removal of gloves using soap and water gloves using soap and water Take care to avoid needle-stick and other sharp injuries. Take care to avoid needle-stick and other sharp injuries. Mouth-mouth resuscitation should be replaced with Mouth-mouth resuscitation should be replaced with mouth piece, resuscitation bag or other ventilation mouth piece, resuscitation bag or other ventilation devices. devices.
- 198. Precaution in relation to injection and skin Precaution in relation to injection and skin piercing piercing To restrict injections and skin piercing. To restrict injections and skin piercing. Single use disposable instruments should be Single use disposable instruments should be used used
- 199. Precautions in relation to laboratory specimens Precautions in relation to laboratory specimens Should wear gloves handling lab specimens. Should wear gloves handling lab specimens. All open wounds on hands and arms should be covered All open wounds on hands and arms should be covered with water tight dressing. with water tight dressing. Working surfaces should be covered with non- Working surfaces should be covered with non- penetrative materials. penetrative materials. Specimen container lids should be secured to prevent Specimen container lids should be secured to prevent leakage during transport. leakage during transport. Proper disposal of specimen and body fluids in Proper disposal of specimen and body fluids in specified containers. specified containers.
- 200. Precautions in relation to invasive procedures Precautions in relation to invasive procedures Gloves and surgical masks should be worn. Gloves and surgical masks should be worn. Protective glasses or face shield should be worn Protective glasses or face shield should be worn Apron should be worn Apron should be worn Protective boots should be worn if spillage of blood or Protective boots should be worn if spillage of blood or body fluid to foot is expected. body fluid to foot is expected. If a glove is torn or needle-stick, hands should be If a glove is torn or needle-stick, hands should be washed carefully and glove should be changed, the washed carefully and glove should be changed, the needle or instrument involved in accident should be needle or instrument involved in accident should be removed from sterile field. removed from sterile field.
- 201. Laundry Laundry Soiled linen should be bagged after use and not Soiled linen should be bagged after use and not sorted or rinsed in wards or near patients. sorted or rinsed in wards or near patients. Spills of blood and other body fluid on Spills of blood and other body fluid on surfaces surfaces The area should be flooded with appropriate The area should be flooded with appropriate disinfectant ( Sodium Hypochlorite, or 0.1-0.5% disinfectant ( Sodium Hypochlorite, or 0.1-0.5% available chlorine) available chlorine)
- 202. Disposal of infected wastes Disposal of infected wastes Needles and sharp instruments or materials in Needles and sharp instruments or materials in Red Container. Red Container. Liquid waste such as bulk blood, suction fluids, Liquid waste such as bulk blood, suction fluids, excretions and secretions should be carefully excretions and secretions should be carefully poured down to sewer system. poured down to sewer system. Solid wastes should be treated by Solid wastes should be treated by incineration incineration or burning or burning. .
- 203. Procedure in the event of contamination with infected blood Immediately clean the contaminated area by washing under running water Post exposure prophylaxis to HIV start within 1 hour of the injury (Zidovudine 250 mg twice daily, lamivudine 150 mg twice daily and indinavir 800 mg three times daily for 1 month) Hepatitis prophylaxis should then be given
- 204. Baseline HIV test should be carried out immediately HIV test should then be repeated 12 weeks after contamination to determine whether seroconversion has occurred