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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
Investigations of anastomotic leak?
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)
26
Management of anastomotic leak - initial management?
 NBM (may need TPN if long-term NBM)  Broad spectrum IV antibiotics  IV fluids  Urinary catheter
27
Management of anastomotic leak - definitive management?
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
28
Definition of atelectasis?
o Partial collapse of small airways resulting in abnormal lung function o Important as precursor to post-op pulmonary complications
29
Pathology of atelectasis?
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)
30
Risk factors of atelectasis?
``` o Age o Smoking o General Anaesthesia o Long surgery o Prolonged bed rest o Poor post-operative pain control ```
31
Symptoms of atelectasis?
o Develops within 24h of surgery o Increased RR o Reduced O2 sats o Low grade fever
32
Investigations of atelectasis?
o CXR – small areas of airway collapse | o Ct more sensitive if unclear
33
Management of atelectasis?
o Oxygen (if low sats) o Deep breathing exercises o Chest physio
34
Definition of infectious mononucleosis (EBV)?
- 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
35
Epidemiology of infectious mononucleosis (EBV)?
- 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
Cause of infectious mononucleosis (EBV)?
- Caused by the Epstein-Barr virus (EBV), a member of the human herpes virus family (hHV4)
37
Incubation period of infectious mononucleosis (EBV)?
33-49 days
38
Spread of infectious mononucleosis (EBV)?
contact with saliva through kissing or sharing food and drink
39
Symptoms of infectious mononucleosis (EBV)?
- 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
Diagnostic confirmation of infectious mononucleosis (EBV) - in >12 year olds?
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
Diagnostic confirmation of infectious mononucleosis (EBV) - in <12 year olds or immunocompromised?
o Bloods for EBV IgM serology after person ill for >7 days | o If two monospots negative – test for CMV and toxoplasmosis
42
Other investigations to consider in infectious mononucleosis (EBV)?
LFTs – Raised AST/ALT
43
Management of infectious mononucleosis (EBV)?
- 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
When to admit patient with infectious mononucleosis (EBV)?
- Glandular fever confirmed/suspected & stridor/dehydration/suspected splenic rupture/complications
45
Prognosis of infectious mononucleosis (EBV)?
- Disease is self-limiting and lasts 2-3 weeks | - Sore throat severe for 3-5 days then resolves over a week
46
Complications of infectious mononucleosis (EBV)?
- 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
Description of antibiotic associated diarrhoea (C.diff infection)?
- 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
Spread of C.diff?
- Spread via faecal-oral or spores (which live on environmental surfaces)
49
Epidemiology of C.diff?
- 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
Risk factors of C.diff?
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
Risk factors of fulminant C.diff colitis?
>70, leucocytosis, haemodynamically unstable
52
Symptoms and signs of C.diff?
- Pyrexia - Colic Pain - Diarrhoea – watery stools, pain relieved by defaecation and urgency
53
Severity assessment of C.diff?
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
Tests to perform if suspected of C.diff?
o Stool Sample  If symptomatic and contact with person with C.diff or recent antibiotics/PPIs/hospital admission o Bloods  FBCs, U&Es
55
Management of C.diff - if severe?
admit to hospital
56
Management of C.diff - if admission not needed?
 Stop antibiotic  Manage fluid losses and symptoms as for gastroenteritis  Avoid loperamide  Hygiene advice
57
Management of C.diff -in hospital - if C.diff positive?
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
Complications of C.diff?
- Pseudomembranous colitis - Toxic megacolon - Perforation of colon - Sepsis - Death
59
Prognosis of C.diff?
- Mortality – up to 25% in frail patients | - Recurrence – 20% for 1st episode and 50% after 2nd episode
60
Definition of MRSA - colonisation and infection?
- 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
Types of MRSA?
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
Epidemiology of MRSA?
- S.aureus nasal carriage in up to 1/3 | - MRSA in 0.5%
63
Cause of MRSA?
Metacillin resistant staphylococcus aureus
64
Transmission of MRSA?
- Transmitted via direct contact with infect skin/contaminated objects or environmental surfaces, enters through tissue
65
Risk factors of hospital-associated MRSA?
``` 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
Risk factors of community acquired MRSA?
o IVDU o MSM o Athletes o Long-term care/prisons
67
Investigations in primary of MRSA?
``` 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
Investigations in secondary care of MRSA?
o Swabs from two sites (anterior nose, groin) & skin lesions/catheters/insertion sites – culture o Repeat screen after 30 days admission
69
Management of MRSA - primary care?
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
Management of MRSA -advice?
 Isolation  Wash hands and stethoscope  Eradication therapy • Mupirocin nasal ointment if nasal carriage o Use Naseptin if 2 failed mupirocin courses  Use PPE
71
Management of MRSA -antibiotics?
 Discuss with microbiologist  Vancomycin (Teicoplanin) • If unsuitable, linezolid
72
Management of MRSA -specific antibiotics?
* 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
Definition of pyrexia of unknown origin?
o Temperature >38.3oC for at least 3 weeks with no obvious source despite investigations (3 days in hospital or two outpatient visits)
74
Infectious causes of pyrexia of unknown origin?
 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
Neoplastic causes of pyrexia of unknown origin?
 Lymphoma |  Solid tumours (GI, renal)
76
Connective tissue disorders of pyrexia of unknown origin?
```  RA  PMR  Still’s disease  GCA  SLE  Kawasaki disease ```
77
Other causes of pyrexia of unknown origin?
```  Drugs  PE  Stroke  IBD  Sarcoid/Amyloidosis ```
78
Fever patterns in patient of pyrexia of unknown origin?
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
Signs of bacteraemia of pyrexia of unknown origin?
``` o Confusion o Renal failure o Neutrophilia o Low plasma albumin o Raised CRP ```
80
Investigations of pyrexia of unknown origin?
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
Management of pyrexia of unknown origin?
- 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
Timeline of post-operative complications - intraoperative?
Bleeding Damage to structures Anaesthetic risks Allergic reactions
83
Timeline of post-operative complications - 1-3 days post-op?
Bleeding MI/Stroke Atelectasis
84
Timeline of post-operative complications - 3-7 days post-op?
Infection (wound, chest, urine) Anastomotic leak DVT/PE
85
Timeline of post-operative complications - months after surgery?
Hernia Chronic Pain Recurrence

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