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MSRA Content > Infection - Level 1 > Flashcards

Infection - Level 1 Flashcards

1
Q

Preventative measures of surgical site infections in theatre?

A

o Staff preparation
o No hand jewellery, artificial nails, nail polish
o Hand decontamination
o Staff theatre wear and sterile gowns

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2
Q

Patients preparation before surgery to prevent surgical site infections?

A

o Advise patient to have shower using soap, either day before or on day of surgery
o If hair removal needed, use single use electric clippers on day of surgery (shaving increases risk of infection)
o Antibiotic prophylaxis
 Give to clean surgery involving placement of prothesis or implant, clean-contaminated surgery and contaminated surgery
 Give single dose IV antibiotics before surgery

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3
Q

Wound management in prevention of surgical site infections?

A

o Aseptic dressing changes
o Use sterile saline for wound cleansing up to 48 hours after surgery
o May shower safely 48 hours after surgery
o Tap water for wound cleansing after 48 hours if the surgical wound has separated or has been surgically opened to drain pus

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4
Q

Definition of wound dehiscence?

A
  • Wound fails to heal and re-opens a few days after surgery
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5
Q

Types of wound dehiscence?

A

o Superficial dehiscence – skin wound alone fails

o Full thickness dehiscence – rectus sheath fails to heal and bursts with protrusion of small bowel and omentum

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6
Q

Risk factors of wound dehiscence?

A

o Patient
 Age, male, DM, steroids, smoking, obesity

o Intra-operative
 Emergency surgery, abdominal surgery, long surgery, wound infection (most common), poor technique

o Post-operative
 Prolonged ventilation, blood transfusion, patient coughing, radiotherapy

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7
Q

Clinical features of wound dehiscence?

A

o Visible opening of wound, healing poorly following operation
o Typically, 5-7 days post-operatively
o Full thickness dehiscence – bulging of wound and seepage of pink serous or blood-stained fluid

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8
Q

Investigations of wound dehiscence?

A

o Clinical diagnosis
o If infection – wound swabs for culture
o Bloods – FBC, CRP, blood cultures (if signs of sepsis)

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9
Q

Management of superficial wound dehiscence?

A

 Washing out wound with saline and then wound care (pack with gauze)
 Wound heals by secondary intention which may take several weeks
 Larger wounds – Vacuum-assisted closure full thickness

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10
Q

Management of full wound dehiscence?

A 
	Analgesia
	IV fluids
	Broad spectrum IV antibiotics
	Cover wound in saline-soaked gauze
	Urgent return to theatre for re-closure of wound – large uninterrupted sutures
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11
Q

Definition of surgical site infections?

A
  • Infection that occurs in the incision created by surgical procedure
  • Doubles mortality rates and increasing overall length of stay
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12
Q

Risk factors of surgical site infections?

A 
Patient Factors
	Age, poor nutritional states
	DM
	CKD
	Immunosuppression
	Smoker
Operation Factors
	Preoperative shaving
	Long operation
	Insertion of surgical drain
	Poor wound closure
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13
Q

Symptoms of surgical site infections?

A 
o	Appear 5-7 days post-procedure – can be weeks after
o	Spreading erythema
o	Localised pain
o	Pus/Discharge from wound
o	Wound dishiscence
o	Persistent pyrexia
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14
Q

Investigations of surgical site infections?

A

o Wound swab – cultures

o Bloods – FBC, CRP, cultures (if systemic features)

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15
Q

Management of surgical site infections?

A

o Remove sutures or clips, allow drainage of pus
o Empirical antibiotics (follow local guidelines depending on wound)
 Tailor according to culture

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16
Q

Definition of stoma?

A

Stoma = created opening into hollow organ, covered by removable pouch that collects output for disposal
o E.g. – colostomy (opening into large bowel), ileostomy (ileum), urostomy (urinary system)

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17
Q

Inspecting stoma - site?

A

LIF (colostomy), RIF (ileostomy)

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18
Q

Inspecting stoma - spout?

A

spouted = ileostomy as small bowel contents irritant, flush to skin = colostomy

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19
Q

Inspecting stoma - consistency?

A

colostomy output is thick and sludgy, whereas ileostomy is waterier and greener

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20
Q

Inspecting stoma - complications?

A

Stenosis
Hernia
Prolapse
Retraction
Dehiscence of stoma
o If healthy looking & no bowel herniating – clean and encourage secondary healing
o If red, infected, bowel herniating – emergency surgery

Infarction (jet black)
o Caused by:
 Tight opening – need surgery to excise & replace
 Bowel necrosis – emergency surgery

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21
Q

Palpation of stoma?

A

 Ask to cough to feel parastomal hernia

 Digitate stoma to assess stenosis and patency

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22
Q

Definition of anastomotic leak?

A
  • Leak of luminal contents from surgical join, usually following GI surgery
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23
Q

Risk factors of anastomotic leak?

A 
o	Steroids
o	DM
o	Obesity
o	Emergency surgery
o	Long operation
o	Oesophageal-gastric or rectal anastomosis
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24
Q

Symptoms and signs of anastomotic leak?

A

o Usually 5-7 days post-operative
o Abdominal pain and fever
o Prolonged ileus
o Delirium

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25
Q

Investigations of anastomotic leak?

A

Patients not progressing as expected or deteriorating after surgery should be suspected to have an anastomotic leak until proven otherwise
o Urgent CT scan with contrast of abdomen and pelvis
o Urgent Bloods (FBC, CRP, U&E, LFTs, clotting, VBG)

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26
Q

Management of anastomotic leak - initial management?

A

 NBM (may need TPN if long-term NBM)
 Broad spectrum IV antibiotics
 IV fluids
 Urinary catheter

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27
Q

Management of anastomotic leak - definitive management?

A

o Urgent Senior review
 Minor leaks – conservative – IV antibiotics
 Large leaks – Percutaneous drainage
 Large leaks with sepsis – exploratory laparotomy with wash outs and drain insertions

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28
Q

Definition of atelectasis?

A

o Partial collapse of small airways resulting in abnormal lung function
o Important as precursor to post-op pulmonary complications

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29
Q

Pathology of atelectasis?

A

o Airway collapse due to combination of airway compression, alveolar gas resorption intra-operatively and impaired surfactant production
o Reduced airway expansion predispose to pulmonary complications (hypoxia, reduced lung compliance, infection, ARDS)

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30
Q

Risk factors of atelectasis?

A 
o	Age
o	Smoking
o	General Anaesthesia
o	Long surgery
o	Prolonged bed rest
o	Poor post-operative pain control
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31
Q

Symptoms of atelectasis?

A

o Develops within 24h of surgery
o Increased RR
o Reduced O2 sats
o Low grade fever

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32
Q

Investigations of atelectasis?

A

o CXR – small areas of airway collapse

o Ct more sensitive if unclear

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33
Q

Management of atelectasis?

A

o Oxygen (if low sats)
o Deep breathing exercises
o Chest physio

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34
Q

Definition of infectious mononucleosis (EBV)?

A
  • Glandular fever is an infectious, usually self-limiting disease
  • Virus has tropism for B lymphocytes and epithelial cells of pharynx
  • EBV infection leads to a lifelong latent carrier state
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35
Q

Epidemiology of infectious mononucleosis (EBV)?

A
  • 50% of children will have detectable EBV antibodies by 5 years of age
  • 90% of people will have antibodies by 25 years of age
36
Q

Cause of infectious mononucleosis (EBV)?

A
  • Caused by the Epstein-Barr virus (EBV), a member of the human herpes virus family (hHV4)
37
Q

Incubation period of infectious mononucleosis (EBV)?

A

33-49 days

38
Q

Spread of infectious mononucleosis (EBV)?

A

contact with saliva through kissing or sharing food and drink

39
Q

Symptoms of infectious mononucleosis (EBV)?

A
  • Most people are asymptomatic
  • In most people, the disease is self-limiting and lasts 2–3 weeks
  • Symptoms:
    o Fever
    o Malaise, myalgia, rigors, anorexia
    o Lymphadenopathy
    o Tonsillopharyngitis – sore throat
     Enlargement, whitewash exudate of tonsils and palatal petechiae
    o Hepatosplenomegaly
    o Maculopapular rash
    o Jaundice
40
Q

Diagnostic confirmation of infectious mononucleosis (EBV) - in >12 year olds?

A

o FBC with differential WCC and Monospot heterophile test in 2nd week of illness

 Lymphocytosis with >20% atypical or reactive lymphocytes or >10% atypical lymphocytes and >50% of total WCC

 If Monospot negative and still symptoms – repeat after 1 week

 If rapid diagnosis needed – blood for EBV IgM serology

41
Q

Diagnostic confirmation of infectious mononucleosis (EBV) - in <12 year olds or immunocompromised?

A

o Bloods for EBV IgM serology after person ill for >7 days

o If two monospots negative – test for CMV and toxoplasmosis

42
Q

Other investigations to consider in infectious mononucleosis (EBV)?

A

LFTs – Raised AST/ALT

43
Q

Management of infectious mononucleosis (EBV)?

A
  • Supportive
    o Ibuprofen and paracetamol
  • Avoid kissing, sharing eating or drinking utensils and clean all items thoroughly
  • Avoid contact sports or heavy lifting for 1 month of illness (risk of splenic rupture)
  • If airway compromised, then corticosteroids could be used
  • AVOID AMPICILLIN/AMOXICILLIN AS CAUSES MACULOPAPULAR RASH IN CHILDREN AFFECTED WITH EBV
44
Q

When to admit patient with infectious mononucleosis (EBV)?

A
  • Glandular fever confirmed/suspected & stridor/dehydration/suspected splenic rupture/complications
45
Q

Prognosis of infectious mononucleosis (EBV)?

A
  • Disease is self-limiting and lasts 2-3 weeks

- Sore throat severe for 3-5 days then resolves over a week

46
Q

Complications of infectious mononucleosis (EBV)?

A
  • Upper Airway Obstruction – due to tonsil enlargement or quinsy
  • Splenic rupture – usually occurs 3 weeks after acute illness
  • Neurological – aseptic meningitis, encephalitis, facial nerve palsy, GBS, optic neuritis, hemiplegia
  • Haemolytic anaemia
  • Thrombocytopenia
  • Neutropenia
  • Pericarditis and myocarditis
  • Abnormal AST/ALT LFTs
  • Risk factor for Burkitt’s lymphoma, Hodgkin’s lymphoma, B-cell lymphoma and other cancers
47
Q

Description of antibiotic associated diarrhoea (C.diff infection)?

A
  • Antibiotics cause diarrhoea via one of following mechanisms:
    o Disruption of bowel microbiota and mucosal integrity
    o Direct effect of antibiotic (erythromycin increases gastric emptying)
    o Overgrowth of toxin-producing strains of Clostridium difficile (Gram-positive anaerobic bacillus)
48
Q

Spread of C.diff?

A
  • Spread via faecal-oral or spores (which live on environmental surfaces)
49
Q

Epidemiology of C.diff?

A
  • 20-30% of antibiotic associated diarrhoea due to C.diff

- Asymptomatic colonisation of C.diff in up to 2% of adults, up to 50% in infants

50
Q

Risk factors of C.diff?

A

o >65
o Antibiotics - Clindamycin, cephalosporins, fluroquinolones, broad-spectrum penicillins (ampicillin, amoxicillin, co-amoxiclav)
o Hx of C.diff
o Exposure to other cases
o PPI/H2RA use
o Abdominal surgery, CKD, IBD, immunosuppression
o Hospitalisation

51
Q

Risk factors of fulminant C.diff colitis?

A

> 70, leucocytosis, haemodynamically unstable

52
Q

Symptoms and signs of C.diff?

A
  • Pyrexia
  • Colic Pain
  • Diarrhoea – watery stools, pain relieved by defaecation and urgency
53
Q

Severity assessment of C.diff?

A

o Mild – no leucocytosis, <3 episodes of loose stools per day
o Moderate – Leucocytosis, 3-5 loose stools per day
o Severe – WCC >15x109/L, temperature >38.5, increased serum creatinine
o Life threatening – hypotension, ileus, toxic megacolon, CT evidence of severe disease

54
Q

Tests to perform if suspected of C.diff?

A

o Stool Sample
 If symptomatic and contact with person with C.diff or recent antibiotics/PPIs/hospital admission

o Bloods
 FBCs, U&Es

55
Q

Management of C.diff - if severe?

A

admit to hospital

56
Q

Management of C.diff - if admission not needed?

A

 Stop antibiotic
 Manage fluid losses and symptoms as for gastroenteritis
 Avoid loperamide
 Hygiene advice

57
Q

Management of C.diff -in hospital - if C.diff positive?

A

Antibiotics - Mild-moderate 1st episode:
• Oral metronidazole 400mg TDS for 10-14 days

Antibiotics - Severe 1st episode or second or subsequent episodes:
• Vancomycin 125mg QDS PO for 10-14 days (fidaxomicin can be used for subsequent episodes)

If not responding – oral vancomycin + IV metronidazole for 10-14 days

Avoid loperamide, review daily in primary care, do not return to work until free of diarrhoea for 48 hours

58
Q

Complications of C.diff?

A
  • Pseudomembranous colitis
  • Toxic megacolon
  • Perforation of colon
  • Sepsis
  • Death
59
Q

Prognosis of C.diff?

A
  • Mortality – up to 25% in frail patients

- Recurrence – 20% for 1st episode and 50% after 2nd episode

60
Q

Definition of MRSA - colonisation and infection?

A
  • Strains of S.Aureus which are resistant to common antibiotics (B-lactams – flucloxacillin)
    o Colonisation = people carry MRSA on skin, gut or nose but no symptoms
    o Infection = MRSA causes harm and requires treatment
61
Q

Types of MRSA?

A

o Healthcare-associated MRSA – had contact with healthcare services, inpatient >48 hours
o Community-associated MRSA – identified in community setting or within 48 hours of hospital admission

62
Q

Epidemiology of MRSA?

A
  • S.aureus nasal carriage in up to 1/3

- MRSA in 0.5%

63
Q

Cause of MRSA?

A

Metacillin resistant staphylococcus aureus

64
Q

Transmission of MRSA?

A
  • Transmitted via direct contact with infect skin/contaminated objects or environmental surfaces, enters through tissue
65
Q

Risk factors of hospital-associated MRSA?

A 
o	Admission
o	Resident in long term care or crowded facilities
o	Previous exposure to antibiotics
o	Hx of MRSA infection/colonisation
o	IVDU
o	Immunosuppression
66
Q

Risk factors of community acquired MRSA?

A

o IVDU
o MSM
o Athletes
o Long-term care/prisons

67
Q

Investigations in primary of MRSA?

A 
o	Consider MRSA if patient with potential S.aureus infection which:
	Has risk factors for MRSA
	No response to treatment
	Recurrent skin infections
o	If patient well – sample for M, C
68
Q

Investigations in secondary care of MRSA?

A

o Swabs from two sites (anterior nose, groin) & skin lesions/catheters/insertion sites – culture
o Repeat screen after 30 days admission

69
Q

Management of MRSA - primary care?

A

o Urgent admission if suspected/confirmed MRSA and complicated infection (sepsis, endocarditis, pneumonia, osteomyelitis)
o If uncomplicated infection:
 Discuss with microbiology and follow up in 48 hours
o Advice:
 Keep all wound, cuts clean and covered until healed
 Wear gloves when changing dressings
 Wash hands with soap and water regularly
 Avoid sharing towels, razors, toothbrushes, soaps, clothing

70
Q

Management of MRSA -advice?

A

 Isolation
 Wash hands and stethoscope
 Eradication therapy
• Mupirocin nasal ointment if nasal carriage
o Use Naseptin if 2 failed mupirocin courses
 Use PPE

71
Q

Management of MRSA -antibiotics?

A

 Discuss with microbiologist
 Vancomycin (Teicoplanin)
• If unsuitable, linezolid

72
Q

Management of MRSA -specific antibiotics?

A
  • Soft-tissue – rifampicin + fusidic acid (mild)
  • Complicated skin/soft-tissue – Tigecycline + daptomycin
  • Bronchiectasis + UTI – Tetracycline
  • Sepsis – Vancomycin
  • Endocarditis – vancomycin + gentamicin
  • Osteomyelitis and septic arthritis - vancomycin
73
Q

Definition of pyrexia of unknown origin?

A

o Temperature >38.3oC for at least 3 weeks with no obvious source despite investigations (3 days in hospital or two outpatient visits)

74
Q

Infectious causes of pyrexia of unknown origin?

A

 Abscesses (lung, liver, subphrenic, perinephric, pelvic)
 Empyema
 Bacteria (salmonella, brucella, borrelia, leptospira)
 Rheumatic fever
 Infective endocarditis
 HIV
 TB
 Toxoplasmosis
 Parasites – amoebic liver abscess, malaria, schistocomiasis, trypanosomiasis
 Fungi
 Typhus

75
Q

Neoplastic causes of pyrexia of unknown origin?

A

 Lymphoma

 Solid tumours (GI, renal)

76
Q

Connective tissue disorders of pyrexia of unknown origin?

A 
	RA
	PMR
	Still’s disease
	GCA
	SLE
	Kawasaki disease
77
Q

Other causes of pyrexia of unknown origin?

A 
	Drugs
	PE
	Stroke
	IBD
	Sarcoid/Amyloidosis
78
Q

Fever patterns in patient of pyrexia of unknown origin?

A

o Always think of malaria, others include: PID, IE, TB, UTI
o Daily spikes – Abscess, TB, schistosomiasis
o Twice-daily spikes – Leishmaniasis
o Saddleback fever (fever for days then normal) – Colorado tick fever, Borrelia, Leptospira, Dengue, Legionnaire’s disease
o Long periodicity – Lymphoma
o Remitting (diurnal variation, not dipping to normal) – Amoebiasis, malaria, Kawasaki disease, CMV, TB

79
Q

Signs of bacteraemia of pyrexia of unknown origin?

A 
o	Confusion
o	Renal failure
o	Neutrophilia
o	Low plasma albumin
o	Raised CRP
80
Q

Investigations of pyrexia of unknown origin?

A

o Bloods
 FBC, ESR, CRP, U&E, LFT, ANA, Rh factor, TFT
 Blood cultures

o Urine, stool, CSF cultures

o Imaging
 CXR
 Abdominal CT scan
 Echocardiogram (if IE suspected)

81
Q

Management of pyrexia of unknown origin?

A
  • Refer and discuss with infectious diseases specialist
  • If clinically stable – watch and wait approach appropriate if extensive investigation shows no diagnosis
  • If clinically unstable or neutropenic – empirical antibiotics
82
Q

Timeline of post-operative complications - intraoperative?

A

Bleeding
Damage to structures
Anaesthetic risks
Allergic reactions

83
Q

Timeline of post-operative complications - 1-3 days post-op?

A

Bleeding
MI/Stroke
Atelectasis

84
Q

Timeline of post-operative complications - 3-7 days post-op?

A

Infection (wound, chest, urine)
Anastomotic leak
DVT/PE

85
Q

Timeline of post-operative complications - months after surgery?

A

Hernia
Chronic Pain
Recurrence

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