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BDS4 CDS Oral Surgery > infection symposium > Flashcards

infection symposium Flashcards

1
Q

symptoms of sepsis

A

confusion or disorientation,
shortness of breath,
high heart rate,
fever, or shivering, or feeling very cold,
extreme pain or discomfort, and.
clammy or sweaty skin.

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2
Q

sepsis definition

A

life threatening organ dysfunction due to a dysregulated host response to infection

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3
Q

septic shock

A

sepsis with presisting hypotension that requires vasopressors to maintain the mean arterial pressure at less than 65mmHg and serum lactate concentration of >2mmoll

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4
Q

qSOFA for sepsis

A

resp rate >/= 22breaths/min
altered thoughts/confusion (GCS<15)
systolic BP </= 100mmHg

if score >/=2 need intervention ASAP (10% morbitiy risk as no sepsis pt)

baseline assume 0 (unless other comorbities - diabetes/CVD)

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5
Q

spred of infection RED FLAGS

6

A
  • temp <36 or >37
  • elevated respiratory rate >20breaths/min
  • elevated or reduced HR (60-100bpm is norm)
  • trisumus due to swelling
  • swelling crossing midline
  • dehydration - reduced urine output
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6
Q

sepsis 6

A

3 IN
* O2 15l -* prevent hypoxia*
* high volume fluids -* prevent hypovolemia and shock*
* IV antibiotics

3 OUT
* monitor urine output
* bloods for culturing, glucose, FBC, Us + Es, CRP, lactate

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7
Q

advantages of pus aspirate over pus swab

2

A

**Infected with oral mucosal flora – harder to interpret results **

Swelling – relive pressure as establish drainage at same time

**Larger sample **

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8
Q

key information on specimen request form

8
order of importance

A
  • Clinician contact details (name, number) – know how to get in contact with you
  • Dx/presumptive dx
  • Investigation: culture and susceptibility testing
  • Pt identifiers
  • Clinical details
  • Date/time taken
  • Specimen details
  • Site
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9
Q

key safety elements when submitting microbiological/pathological materials to clinical lab

specimen safety

4

A

Needle in sharps container – clinicians responsibly
* Remove needle safely over sharps bin – twist off

Syringe cap – red plastic to seal end of syringe, prevent it flowing out accidentally

Puts pts label around syringe so its ready to go

Fill in request form

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10
Q

Key safety elements when submitting microbiological or pathological materials to clinical laboratories

packaging requirements

3

A

Need 3 layers of packing
* First layer need something absorbent incase something spills or leaks from sample
* Needs to be compliant with UN3373 standard (legal requirement)

Secure

Labelled

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11
Q

gram stain for gram positive

A

purple

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12
Q

gram stain for gram negative

A

pink

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13
Q

what is A

A

neutrophil (pus has lots of dead neutrophils)

Polymorphor nuclear leukocyte

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14
Q

what is B

A

gram positive bacilli

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15
Q

what is C

A

gram negative cocci

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16
Q

clinical example of use of gram stain from pus of a dental abscess

A

Lab can identity type of bacteria present in the infection and as result as suitable antibiotics to which the bacteria is sensitive to can be prescribed (reduced AB resistance as pt is being correct AB)
* Informs empiric choice of AB
* Narrow down with signs/symptoms/history in SEPSIS case – start broad – when get testing back narrow down more

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17
Q

describe Gram stain of this isolate from an infection in dento-alveolar bone
What is the most likely identity?
What is the preferred antibiotic of choice to treat this micro-organism

A

Mix of gram pos cocci and gram neg

**Gram positive cocci – stap aureus looks like grapes
* **Cause abscess, can be found in angular cheilits, implantitis. Also cause bad abdo and skin infections etc **

Preferred antibiotics is flucloxacillin
* Resistant to amoxicillin, penicillin, metronidazole

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18
Q

preferred antibiotics for gram positive cocci

A

flucloxacillin

resistant to amoxicillin, penicillin, metronidazole

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19
Q

example gram positive cocci

A

staph aureus

looks like grapes

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20
Q

Gram stain of this isolate from an acute peri-apical abscess.
What is the most likely identity?
What is the preferred antibiotic of choice to treat this micro-organism

A

Gram positive cocci – all in chain

Strep angiosus
*Phenoxymethylpenicillin – used for strep

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21
Q

full name for penV

A

Phenoxymethylpenicillin

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22
Q

Phenoxymethylpenicillin used for

A

streptococcus angiosus

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23
Q

flucloxacillin used for

A

staphylcoccus aureus

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24
Q

WHO definition of antibiotic resistance

A

“Antimicrobial resistance occurs when microorganisms such as bacteria, viruses, fungi and parasites change in ways that render the medications used to cure the infections they cause ineffective”

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25
Q

describe this chart used to measure antibiotic reistance in the lab

A

MIC = Minimal Inhibitory Concentration
A - sensitive
B – breakpoint
C – resistant

26
Q

European Committee on Antimicrobial Susceptibility Test (EUCAST)
antibiotic resistnace clinically defined as

A

When infection is highly unlikely to respond even to maximum doses of antibiotics

27
Q

3 examples of clinical factors that influence the penetration of antibiotics to the site of infection

A
  1. biofilm disruption
  2. pus collection
    3.site of infection
28
Q

oral black pigmenting anaerobe e.g.

A

Prevotella Intermedia

29
Q

most common type of resistance mechanism for beta-lactams in BPA’s. Choose from;

A

Enzymatic inactivation (Beta-lactamase)

30
Q

why is Pen V not the first line beta-lactam for the management of dento-alveolar infections

A

Equally effective as Amoxicillin but less harmful to resident flora
*
Narrower spectrum so less harm to gut flora etc – but still only when needs to be prescribed*

31
Q

Which of the following micro-organisms from dental infections are usually susceptible to metronidazole

a. Streptococcus anginosus
b. Staphylococcus aureus
c. Peptostreptococcus micros
d. Actinomyces israellii
e. Streptococcus mutans

A

Anaerobic Bacterial Infections (GRAM NEGATIVE)

c. Peptostreptococcus micros

and prevotella intermedia

Strict Anaerobes Only

32
Q

Which of the following mechanisms is likely to result in metronidazole resistance
a.Enzymatic inactivation
b.Modified target
c.Decreased uptake
d.Increase efflux
e. All of the above

A

e. All of the above

33
Q

anticrobial strewardship is

A

a coordinated program that promotes the appropriate use of antimicrobials (inc antibiotics), improves pt outcomes, reduced microbials resistance and decreases the spread of infections caused by multi-drug resistant organisms

34
Q

pus sampling role in antimicrobial stewardship

A

Prescribing antibiotics that would be ineffective for that infection
* Contributing to resistance
* Reduce pt success outcome
* Inc risk of spreading infection

35
Q

barriers in GDP to pus sampling

A
  • Time
  • Money
  • Lack of equipment
  • Lack of clinical knowledge on how to sample and transport sample
36
Q

what to do when someone presents with a large swelling

(infection spreading)

A

Quick assess- ABCDE – breathing, able to walk/sit, understand
* Hot potato voice– raise tongue and FOM, see less of oropharynx, unable to speak properly

Then
History – when dd it start, how long, change rapidly – how quickly
Medical – allergies, RED FLAGS - immunocompromised, diabetic (esp if not well controlled – worse quicker and poor healing – check HbA1c value 48mmol/mol) and renal problems or bleeding disorders
SH – live alone, smoking (don’t heal well, exacerbate everything in the mouth), alcohol,

and E/O and I/O

37
Q

E/O assessment for spread of infection focus

A

asymmetry,
swelling (palpate – site, shape, size (use ruler)- fixed, firm, heat, obstructing eye or lower mandible),
lymphadenopathy – check all, **can you feel border of mandible, **
check jaw opening (guarding - scared and/or painful; get them to open to max opening even if its painful; place fingers on their incisal edges – will feel hard to open more; if just owww – not true trismus; true trismus if submasseteric swelling)

38
Q

I/O assessment for spread of infection focus

A

any sign obvious sources of infection
quick survey,
able to do any TTP/mobility checks,
any sinus,
loss of sulcus depth – swelling gone into space and able to incise it,

check tongue position and FOM – need to be able to palpate – if unilateral take finger on FOM on unaffected and then affect – should be soft, not raised or not lumpy – will feel more than see,

check oropharynx and uvular– warn pt will depress tongue (deviation)

Hot potato voice– raise tongue and FOM, see less of oropharynx, unable to speak properly

39
Q

special investigations for spread of infection?

A

Get xrays if you can – compare with old if possible

Measure HR, temp, o2 sats, BP (internal better than external) – use right cuff for pt size

Normal
* 36 degrees +/- degree
* 60-100bpm (whats normal for them – children higher than adults)
* 120/80, 60-90 (systolic/diastolic)
* 95-100 O2 sats (COPD – carbon diox driven so will be lower)*

40
Q

normal values for
temp
HR
BP
O2 sats

A
  • 36 degrees +/- degree
  • 60-100bpm (whats normal for them – children higher than adults)
  • 120/80, 60-90 (systolic/diastolic)
  • 95-100 O2 sats (COPD – carbon diox driven so will be lower)*
41
Q

maxillary spread of infection

A
  • canine space (high risk for eye involvement) – will look like blistered eye or puffy eye;
  • palatal space
42
Q

manidbular spread of infectin

A

buccal
submental
submasseteric
sublingual

43
Q

SIRS

A

serious inflammatory response syndrome

(used to assess SEPSIS)

44
Q

4 components of SIRS

A
  • tachycardia (heart rate >90 beats/min),
  • tachypnea (respiratory rate >20 breaths/min),
  • fever or hypothermia (temperature >38 or <36 °C),
  • leukocytosis, leukopenia, or bandemia (white blood cells >1,200/mm3, <4,000/mm3 or bandemia ≥10%)
45
Q

when to speak to maxfax

A

maintaining airway and breathing ok but couple of worrying signs - phone
* Know where the closest is, have their number ask for Maxillofacial on call SHO – can be on hold if they are operating
* Have a clear concise relevant history ready to present with temp and obvs
* They will give advice – ask you to do x, y, z or get them in (advise pt to not eat or drink anything on route)

get them to A&E if rapidly swelling that needs IV AB not oral; hard swelling over body of mandible – hard and trapped in facial spaces, needs draining, why feeling mandible imp; if they are high risk pt; showing any signs of sepsis – warranted as spreading
* If cant get them send to A&E with letter – with history and your details, best to try and get in touch with them

tell pt no eating or drinking till been triaged at hospital

Need maxfax for incision and drainage sometimes because **we cannot incise extraorally **– not safe because could hit a major blood vessel,

Cross midline – get ambulance

46
Q

if localised intraorally swelling what should GDP do

A

incise to bone approx 1cm, be careful of mental foramen and nerves
* clear liquid first, then yellow pus - scoop out with Howarth’s, can rinse with saline too

leave to drain (don’t suture)
analgesia advice and come back in 5days

47
Q

2 most common dental infections

A

Dental abscess
Pericoronitis

48
Q

abscess of upper 6
spread options

5

A

Out socket
Buccal space
Maxillary sinus
Palate
Infraorbital

49
Q

abscess of lower 3rd molar
spread options

4

A

Submasseteric
Submental
Sublingual
Pharyngeal spaces – esp lateral pharyngeal concerns – as compromised airway

50
Q

abscess of canine
spread options

A

canine space, cavernous sinus thrombosis
concern – as spread to brain risk

51
Q

basic steps in management of infection in GDP

6

A

History
Examination
Resuscitative ABC and supportive tx
Special investigations
**Remove source of infection +/- I&D of swelling **
possible antibiotics

52
Q

key history questions for infection

A

When did it start – rapid progressively, or slower over weeks
If they can open their mouth
Are they in pain
Have they had any recent dental issues or dental work
Changes to medical history – allergies, medications, red flag illnesses
Quick dental and social history
Alcohol and blood clotting?

53
Q

cellulitis swelling telltale

A

hard

54
Q

fluctuant swelling inficates

A

fresh swelling, more able to drain

55
Q

optiosn for removing source of infection

3

A

XLA
RCT/Pulp extirpate
incision and drain

56
Q

why may not be able to get a pt numb

A

abscess suppuration is acidic, LA is weak bases, pKa process means it will not work

*Mepivacaine is plain so slight differ pH properties – maybe worth trying

Or just I&D and hopefully next time will be able to get numb as some suppuration escape
*

57
Q

do you stitch over I&D

A

no
tell pt will have blood and pus escaping from it and will be able to definitive tx hopefully when they come back in

58
Q

factors to consider when determining severity of infectino

A

Onset
progression
history
trismus
systemic symptoms
Pt factors e.g. diabetic or on steroids

59
Q

when to use antibiotics

A
  • Local measures failed- XLA and area still swollen on review
  • Pt is systemically unwell – determined by pt obs
  • Cellulitis present - hard shiny swelling
  • Infection spreading rapidly
60
Q

3 key red flags for A&E and maxfax

A

Significant trimsus, FOM swelling or diff breathing

61
Q

things to warn pt off when pulp extirpate in emergency setting

A

Advice guarded prognosis –
* will need to assess restorablity of teeth once all the dental caries removed
* large abscess could reduce RCT success,

need pt to come back for more tx

BDS4 CDS Oral Surgery (19 decks)

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