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surgical infections Flashcards

1
Q

what are concentrated in the region of bacterial invasion

A

complement, fibrinogen, and opsonins

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2
Q

what are concentrated in the region of bacterial invasion

A

complement, fibrinogen, and opsonins

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3
Q

mc type of SSI

A

superficial and incisional- range from simple cellulitis of the wound to overt infection of the wound bed above the fascia

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4
Q

tx superficial and incisional SSI

A

oral abx (most are gram pos) for cellulitis and reopening of the wound for those w infx w incisional purulent drainage and involvement of deeper tissues

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5
Q

deep incisional SSI

A

extend into muscle and fascia; require opening and freq surgical debridement of necrotic tissue

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6
Q

wounds at what location are at high risk for fascial necrosis and dehiscence

A

abdomen

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7
Q

tx deep incisional SSI

A

abx and cont daily local wound care

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8
Q

more severe forms of deep incisional SSI

A

necrotizing fasciitis, systemic infx, sepsis

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9
Q

ex of infx of organ/intracavitary space

A

peritonitis, intra abdominal abscess and empyema

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10
Q

surgical skin prep

A

povidone-iodine solution or chlorhexidine containing solutions

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11
Q

what are 2 key preventive measures

A

adequate tissue perforation and oxygenation

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12
Q

minimum inhibitory concentration

A

refers to the lowest concentration necessary to visibly inhibit growth under typical conditions

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13
Q

to insure adequate serum and tissue levels, initial abx are given how long prior to incision

A

1hr

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14
Q

abx for cardiac or vascular

A

cefazolin (ancef), cefuroxime, or vanco

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15
Q

abx for hip/knee arthroplasty

A

cefazolin (ancef), cefuroxime, or vanco

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16
Q

abx colon

A

Cefotetan, cefoxitin, ampicillin/sulbactam or ertapenem

OR

Cefazolin or cefuroxime + metronidazole

If β-lactam allergy:

Clindamycin + aminoglycoside or quinolone or aztreonam

OR

Metronidazole with aminoglycoside or

Metronidazole + quinolone

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17
Q

abx hysterectomy

A

cefotetan, cefazolin, cefoxitin, cefuroxime or Ampicillin/sulbactam

If β-lactam allergy

Clindamycin + aminoglycoside or quinolone or aztreonam

OR

Metronidazole + aminoglycoside or

Metronidazole + quinolone

OR

Clindamycin monotherapy

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18
Q

how long is periop abx therapy cont for

A
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19
Q

6 key quality indicators related to the periop manag of surgical pts that related to surgical infx according to SCIP and CMS

A
  1. Prophylactic antibiotic delivery within 60 minutes prior to incision
  2. Prophylactic antibiotics consistent with approved guidelines
  3. Cessation of prophylaxis within 24 hours following surgery
  4. Appropriate hair removal (clipping)
  5. Glucose control for cardiac surgery
  6. Normothermia for colorectal surgery
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20
Q

all infx that occur after surgical procedures are considered

A

nosocomial (hospital acquired)

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21
Q

fever that occurs in postop setting can be an early indication of

A

dev infx

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22
Q

W’s of postop fever

A

wind (1-2d), water (2-3d), wound (3-5d), walking (5-7d), W abscess (7-10d), wonder drugs (anytime)

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23
Q

usually early and first cause of temp elev postop

A

lung atelectasis

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24
Q

4 major components to prevent HAP/VAP

A

(1) elevation of the head of the bed to 30°, (2) daily sedation vacation and assessment for weaning, (3) stress ulcer prophylaxis, and (4) venous thromboembolism prevention

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25
Q

a quantitative bronchial aspirate of what of aspirate is dx of invasive infx for VAP

A

> 10^5 organisms/mL

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26
Q

abx use for pts in the hospital 10days

A

10d or immunocomp are at greater risk and abx should cover MRSA and resistant gram negative rods

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27
Q

tx for VAP

A

frequent airway suction;specific abx tx for 8 days

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28
Q

greatest risk factor for dev a UTI

A

presence of an indwelling bladder catheter

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29
Q

dx UTI

A

bacterial cx >100,000

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30
Q

when a postop pt w signs of infx dev a pleural effusion, the composition of fluid should be determined by

A

thoracentesis

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31
Q

transudative effusion

A

due ot inc hydrostatic forces and has low protein content

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32
Q

exudative effusion

A

inc permeability and has high protein content

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33
Q

what helps to differentiate exudates

A

LDH, glucose, pH, cell count, and gram stain

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34
Q

results of exudative effusions due to inflammation

A

pH 3xserum level

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35
Q

tx symptomatic pts or lg volume effusions assoc w characteristics assoc w exudate on thoracentesis

A

adequate drainage of the pleural space must be accomplished; abx

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36
Q

dx of exudate on imaging

A

ct scan w loculated rim enhancing pleural collection

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37
Q

mc cause of intra abd infx in surgical pt

A

perf or leakage from a hollow viscus that leads to bacterial seeding of the peritoneal cavity

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38
Q

2 response to perf or leakage of abd cavity

A

abscess formation or generalized peritonitis

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39
Q

primary peritonitis

A

spontan bacterial peritonitis that occurs wout breach of GI tract or peritoneal cavity, usually mono microbial, and seen in chronic alcoholics

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40
Q

secondary peritonitis

A

polymicrobial and occurs as result of spillage of gut organisms from GI tract or contamination of indwelling catheters

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41
Q

tertiary peritonitis

A

critically ill pts and persists or recurs at least 48hrs after apparent adequate manage, polymicrobial, and reflects a failure of host defense rather than source control

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42
Q

tx for any postop patient that demonstrates signs of systemic sepsis

A

broad spectrum abx

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43
Q

dx postop sepsis

A

blood cx, CT w PO and IV contrast*

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44
Q

blanching erythema of cellulitis caused by

A

group a strep and responds to penicillin tx

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45
Q

cellulitis

A

break in skin barrier, strep, warm to touch, diffuse erythema, tenderness, tx systemic abx and local wound care

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46
Q

furuncle, carbuncle

A

bacterial growth within skin glands/crypts, staph, localized induration, erythema, tenderness, swelling w purulent discharge,tx i/d, abx

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47
Q

hldradenitis suppurativa

A

bacterial growth within apocrine sweat glands, staph, multiple localized subcut abscesses, drainage, commonly axilla and groin, tx i/d small lesions, abx, lg needs wide local excision and skin grafting

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48
Q

lymphangitis

A

infx within lymphatics, strep, diffuse swelling, erythema of distal extremity w areas of inflamed streaks along lymphatic channels, tx local wound care, abx, removal fb, elevation extremity

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49
Q

gangrene, nsti’s

A

destruction of healthy tissue by virulent microbial enzymes, strep/staph/clostridium,Necrotic skin/fascia, swelling and Induration, foul smelling discharge, crepitus with subcutaneous emphysema, frequently with toxic systemic signs and symptoms of sepsis

Radical débridement/amputation of involved tissues, aggressive local wound care with frequent débridement as necessary, parenteral broad-spectrum antibiotics

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50
Q

4 types of necrotizing soft tissue infx (NSTI)

A

cellulitis, fasciitis, myositis, vasculitis

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51
Q

what does non blanching erythema indicate

A

subdermal thrombosis of the nutrient blood supply of the skin; tx surgical debridement, high dose penicillin and clinda

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52
Q

clostridial myonecrosis or clostridial cellulitis

A

fulminant life threatening infx characterized by tissue necrosis and rapidly adv crepitus (gas gangrene); debridement and high dose penicillin

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53
Q

restlessness, headache, masseter muscle stiffness, and muscular contractions in area of the wound

A

tetanus (lockjaw); clostridium tetoni

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54
Q

tx tetanus

A

debridement and cleansing of all wounds in which devitalized, contaminated tissue is present

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55
Q

tetanus prone

A

> 6hr, crush, avulsion, extensive abrasion, burns, frostbite, contaminants (soil, saliva) present

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56
Q

nontetanus prone

A
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57
Q

tetanus prophylaxis

A

unknown or

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58
Q

cause of breast abscess

A

staph

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59
Q

who is at higher risk for breast abscess

A

postpartum women

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60
Q

tx breast abscess

A

i/d, abx, bx

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61
Q

infx within crypts of anorectal canal and present as tender mass in perianal area

A

perirectal abscess

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62
Q

if perirectal abscess involves an invasive infx and results in sub cut tissue necrosis what is tx

A

wide debridement for salvage; colostomy diversion to avoid further soilage to area and sequelae of fecal incontinence if sphincter is involved

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63
Q

paronychia

A

staph infx of proximal fingernail that erupts at sulcus of the nail border

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64
Q

tx paronychia

A

i/d, resection of portion of embedded nail, hot soaks

65
Q

felons

A

deep infx of terminal phalanx pulp space; occur after distal phalanx penetrating injuries and are tx by drainage; removal of nail may be necessary

66
Q

neglected infections of the fingers may result in

A

tenosynovitis; infx extends along tendon sheath

67
Q

organisms of bites human and animals

A

eikenella corrodens for humans and pasteurella for dogs/cats

68
Q

abx for biliary tract infx

A

cefazolin or cefoxitin

69
Q

mc inflammatory and infectious process in biliary tract

A

acute cholecystitis

70
Q

acute peritonitis

A

bacteria present within the normally sterile peritoneal cavity

71
Q

ct finding of peritonitis

A

upright chest roentgenogram commonly shows pneumoperitoneum beneath a hemidiaphragm with acute GI perforation and small amounts of pneumoperitoneum

72
Q

all pts w ulcer assoc perf should be assessed for presence of

A

helicobacter pylori

73
Q

abx for appendix

A

aerobic (e coli) and anaerobic (bacteroides fragilis) coverage

74
Q

cause and tx fungal infx

A

Candida; fluconazole, ketoconazole, miconazole, nystatin

75
Q

3 mc viral illnesses of concern for injury (needle stick)

A

hep B*, hep C, HIV

76
Q

A 32-year-old man is seen in the emergency department 45 minutes after a motor vehicle collision. His only injury is a long linear laceration beginning on the left temporal forehead at the hairline and extending posteriorly for 10 cm. The edges are still bleeding briskly and the EMTs described a large amount of blood at the scene. He did not lose consciousness. His last tetanus booster was 4 years ago. Which of the following is required for tetanus prophylaxis In this patient?

A. Tetanus immune globulin only

B. Nothing further at this time

C. Tetanus toxoid only

D. Tetanus immune globulin followed by a single tetanus toxoid booster

E. Tetanus immune globulin followed by three tetanus boosters

A

Answer: B

Wounds prone to the development of tetanus Include those with extensive contamination with soil, deep puncture wounds from metal objects, exposure Injury complicated with frostbite, and wounds >6 hours from time of Injury (Table 8-8.). Linear lacerations In general are not prone to tetanus. The extent of blood loss does not affect the need for tetanus booster administration. The patient last received tetanus toxoid

77
Q

A 48-year-old man Is being evaluated In the emergency department with fevers, chills, and abdominal pain for the past 24 hours. He has a history of hepatitis C infection following a blood transfusion 14 years ago for a large scalp laceration and orthopedic injuries sustained In a motor vehicle collision. He has not been to a physician for 5 years. He does not smoke or drink alcohol. He takes no medications. His temperature is 39°C and vital signs are: blood pressure (BP) 90/50 mm Hg, pulse 110/minute, and respirations 26/minute. A CT scan shows a single stone in the gallbladder that does not appear to be obstructing. The bile ducts are normal caliber and the gallbladder wall Is not thickened. There Is a moderate amount of fluid, mild small bowel distention, and stranding around the sigmoid colon as well as a small amount of free Intraperitoneal gas around the liver. An aspirate of the peritoneal fluid shows leukocytes and mixed Gram positives and negatives on Gram stain. Laboratory values show a WBC of 19,000/mm3, total bilirubin 1.2 mg/dL, and alkaline phosphatase 40 U/L. In addition to fluid resuscitation and broad-spectrum antibiotics, what is the best step in management?

A. Laparoscopic cholecystectomy

B. Long-term antibiotics only

C. Laparotomy

D. Magnetic resonance cholangiopancreatography (MRCP)

E. Endoscopic retrograde cholangiopancreatography (ERCP)

A

Answer: C

This patient has secondary peritonitis. This usually involves perforation of a hollow vlscus and thus involves contamination of the peritoneal cavity with multiple organisms. Gram stain and culture of the peritoneal fluid usually shows a single organism In patients with primary peritonitis and this can be treated with antibiotics without surgical Intervention. In this scenario, the CT scan shows stranding around the sigmoid and fluid and evidence of free air suggestive of a diverticulitis with fecal peritonitis. Patients with underlying liver disease are prone to gallstones and are a common finding. There Is no evidence of common bile duct obstruction that warrants further investigation since the alkaline phosphatase is normal.

78
Q

A 42-year-old woman Is seen In the infectious disease clinic because of a small laceration. She is a surgeon and was assisting a surgical resident with a colon resection when she was accidentally cut with a scalpel blade during the procedure. She has received all required Immunizations. Antibodies against which virus could be measured in order to assess the effectiveness of the only vaccine to prevent Infection potentially transmitted from the patient to the surgeon during the operative procedure?

A. Human immunodeficiency virus

B. Hepatitis C

C. Hepatitis B

D. Cytomegalovirus

E. Tuberculosis

A

Answer: C

HIV, hepatitis B, hepatitis C, and cytomegalovirus are transmitted by body fluids and blood; therefore, they pose an occupational risk to the surgeon. There Is currently a highly effective vaccine for the prevention of hepatitis B in the host. No such vaccine is available for the other viral Infections. Tuberculosis is not a virus but also poses a risk to health care workers.

79
Q

A 30-year-old man is in the hospital recovering from splenectomy for a ruptured spleen sustained in a motor vehicle collision. He has otherwise been healthy and was not taking medications prior to the injury. A temperature of 102°F Is noted on the second postoperative day. Vital signs are BP 130/80 mm Hg, pulse 100/minute, and respirations 18/minute. His pain is moderately controlled with morphine using patient-controlled analgesia (PCA). Breath sounds are diminished at both bases, more so on the left. His abdomen is mildly distended, soft and tender near the Incision. The incision appears to be healing without a problem. What Is the most likely cause for his fever?

A. Atelectasis and pulmonary infection

B. Peritonitis

C. Urinary tract Infection

D. Suppurative thrombophlebitis

E. Cardiac contusion

A

Answer: A

Early postoperative fever Is usually the result of atelectasis and subsequent pulmonary infection (Table 8-6). In this scenario, because of the close proximity of the left hemidiaphragm to the spleen, an Infiltrate In the left lower lobe of the lung Is a high probability. An adequately drained urinary tract In a young person seldom gives a high fever this early in the postoperative period. Although peritonitis from injury to a surrounding structure during the splenectomy (i.e., pancreas, stomach, or bowel) Is a possibility, It is much less likely than a pulmonary source. Cardiac contusion does not elicit a febrile response.

80
Q

A 25-year-old man is seen in the emergency department because of a painful swollen forearm. Two days ago, he sustained a small laceration to his left forearm while clearing brush. It caused only minor discomfort until about 12 hours ago when the area around the laceration became more red and swollen. He has otherwise been healthy. He takes no medications. His temperature Is 38°C. There is a 2-cm superficial laceration on the dorsum of his left forearm with 15-cm diameter surrounding erythema that is quite tender. The edges of the erythema were marked and 20 minutes later the erythema has extended another cm beyond the mark. The most likely causative organism is

A. methicillin-resistant Staphylococcus aureus.

B. β-Hemolytic Streptococcus A.

C. Escherichia coli.

D. Streptococcus faecalis.

E. Candida albicans.

A

Answer: B

Although cellulitis may be caused by any organism, the most likely early organism would be β-hemolytic Streptococcus A. methicillin-resistant Staphylococcus aureus more commonly causes local Inflammation and pus formation. The other three species are rarely isolated from skin infections but more commonly are seen In infections involving the gastrointestinal tract.

81
Q

mc type of SSI

A

superficial and incisional- range from simple cellulitis of the wound to overt infection of the wound bed above the fascia

82
Q

tx superficial and incisional SSI

A

oral abx (most are gram pos) for cellulitis and reopening of the wound for those w infx w incisional purulent drainage and involvement of deeper tissues

83
Q

deep incisional SSI

A

extend into muscle and fascia; require opening and freq surgical debridement of necrotic tissue

84
Q

wounds at what location are at high risk for fascial necrosis and dehiscence

A

abdomen

85
Q

tx deep incisional SSI

A

abx and cont daily local wound care

86
Q

more severe forms of deep incisional SSI

A

necrotizing fasciitis, systemic infx, sepsis

87
Q

ex of infx of organ/intracavitary space

A

peritonitis, intra abdominal abscess and empyema

88
Q

surgical skin prep

A

povidone-iodine solution or chlorhexidine containing solutions

89
Q

what are 2 key preventive measures

A

adequate tissue perforation and oxygenation

90
Q

minimum inhibitory concentration

A

refers to the lowest concentration necessary to visibly inhibit growth under typical conditions

91
Q

to insure adequate serum and tissue levels, initial abx are given how long prior to incision

A

1hr

92
Q

abx for cardiac or vascular

A

cefazolin (ancef), cefuroxime, or vanco

93
Q

abx for hip/knee arthroplasty

A

cefazolin (ancef), cefuroxime, or vanco

94
Q

abx colon

A

Cefotetan, cefoxitin, ampicillin/sulbactam or ertapenem

OR

Cefazolin or cefuroxime + metronidazole

If β-lactam allergy:

Clindamycin + aminoglycoside or quinolone or aztreonam

OR

Metronidazole with aminoglycoside or

Metronidazole + quinolone

95
Q

abx hysterectomy

A

cefotetan, cefazolin, cefoxitin, cefuroxime or Ampicillin/sulbactam

If β-lactam allergy

Clindamycin + aminoglycoside or quinolone or aztreonam

OR

Metronidazole + aminoglycoside or

Metronidazole + quinolone

OR

Clindamycin monotherapy

96
Q

how long is periop abx therapy cont for

A
97
Q

6 key quality indicators related to the periop manag of surgical pts that related to surgical infx according to SCIP and CMS

A
  1. Prophylactic antibiotic delivery within 60 minutes prior to incision
  2. Prophylactic antibiotics consistent with approved guidelines
  3. Cessation of prophylaxis within 24 hours following surgery
  4. Appropriate hair removal (clipping)
  5. Glucose control for cardiac surgery
  6. Normothermia for colorectal surgery
98
Q

all infx that occur after surgical procedures are considered

A

nosocomial (hospital acquired)

99
Q

fever that occurs in postop setting can be an early indication of

A

dev infx

100
Q

W’s of postop fever

A

wind (1-2d), water (2-3d), wound (3-5d), walking (5-7d), W abscess (7-10d), wonder drugs (anytime)

101
Q

usually early and first cause of temp elev postop

A

lung atelectasis

102
Q

4 major components to prevent HAP/VAP

A

(1) elevation of the head of the bed to 30°, (2) daily sedation vacation and assessment for weaning, (3) stress ulcer prophylaxis, and (4) venous thromboembolism prevention

103
Q

a quantitative bronchial aspirate of what of aspirate is dx of invasive infx for VAP

A

> 10^5 organisms/mL

104
Q

abx use for pts in the hospital 10days

A

10d or immunocomp are at greater risk and abx should cover MRSA and resistant gram negative rods

105
Q

tx for VAP

A

frequent airway suction;specific abx tx for 8 days

106
Q

greatest risk factor for dev a UTI

A

presence of an indwelling bladder catheter

107
Q

dx UTI

A

bacterial cx >100,000

108
Q

when a postop pt w signs of infx dev a pleural effusion, the composition of fluid should be determined by

A

thoracentesis

109
Q

transudative effusion

A

due ot inc hydrostatic forces and has low protein content

110
Q

exudative effusion

A

inc permeability and has high protein content

111
Q

what helps to differentiate exudates

A

LDH, glucose, pH, cell count, and gram stain

112
Q

results of exudative effusions due to inflammation

A

pH 3xserum level

113
Q

tx symptomatic pts or lg volume effusions assoc w characteristics assoc w exudate on thoracentesis

A

adequate drainage of the pleural space must be accomplished; abx

114
Q

dx of exudate on imaging

A

ct scan w loculated rim enhancing pleural collection

115
Q

mc cause of intra abd infx in surgical pt

A

perf or leakage from a hollow viscus that leads to bacterial seeding of the peritoneal cavity

116
Q

2 response to perf or leakage of abd cavity

A

abscess formation or generalized peritonitis

117
Q

primary peritonitis

A

spontan bacterial peritonitis that occurs wout breach of GI tract or peritoneal cavity, usually mono microbial, and seen in chronic alcoholics

118
Q

secondary peritonitis

A

polymicrobial and occurs as result of spillage of gut organisms from GI tract or contamination of indwelling catheters

119
Q

tertiary peritonitis

A

critically ill pts and persists or recurs at least 48hrs after apparent adequate manage, polymicrobial, and reflects a failure of host defense rather than source control

120
Q

tx for any postop patient that demonstrates signs of systemic sepsis

A

broad spectrum abx

121
Q

dx postop sepsis

A

blood cx, CT w PO and IV contrast*

122
Q

blanching erythema of cellulitis caused by

A

group a strep and responds to penicillin tx

123
Q

cellulitis

A

break in skin barrier, strep, warm to touch, diffuse erythema, tenderness, tx systemic abx and local wound care

124
Q

furuncle, carbuncle

A

bacterial growth within skin glands/crypts, staph, localized induration, erythema, tenderness, swelling w purulent discharge,tx i/d, abx

125
Q

hldradenitis suppurativa

A

bacterial growth within apocrine sweat glands, staph, multiple localized subcut abscesses, drainage, commonly axilla and groin, tx i/d small lesions, abx, lg needs wide local excision and skin grafting

126
Q

lymphangitis

A

infx within lymphatics, strep, diffuse swelling, erythema of distal extremity w areas of inflamed streaks along lymphatic channels, tx local wound care, abx, removal fb, elevation extremity

127
Q

gangrene, nsti’s

A

destruction of healthy tissue by virulent microbial enzymes, strep/staph/clostridium,Necrotic skin/fascia, swelling and Induration, foul smelling discharge, crepitus with subcutaneous emphysema, frequently with toxic systemic signs and symptoms of sepsis

Radical débridement/amputation of involved tissues, aggressive local wound care with frequent débridement as necessary, parenteral broad-spectrum antibiotics

128
Q

4 types of necrotizing soft tissue infx (NSTI)

A

cellulitis, fasciitis, myositis, vasculitis

129
Q

what does non blanching erythema indicate

A

subdermal thrombosis of the nutrient blood supply of the skin; tx surgical debridement, high dose penicillin and clinda

130
Q

clostridial myonecrosis or clostridial cellulitis

A

fulminant life threatening infx characterized by tissue necrosis and rapidly adv crepitus (gas gangrene); debridement and high dose penicillin

131
Q

restlessness, headache, masseter muscle stiffness, and muscular contractions in area of the wound

A

tetanus (lockjaw); clostridium tetoni

132
Q

tx tetanus

A

debridement and cleansing of all wounds in which devitalized, contaminated tissue is present

133
Q

tetanus prone

A

> 6hr, crush, avulsion, extensive abrasion, burns, frostbite, contaminants (soil, saliva) present

134
Q

nontetanus prone

A
135
Q

tetanus prophylaxis

A

unknown or

136
Q

cause of breast abscess

A

staph

137
Q

who is at higher risk for breast abscess

A

postpartum women

138
Q

tx breast abscess

A

i/d, abx, bx

139
Q

infx within crypts of anorectal canal and present as tender mass in perianal area

A

perirectal abscess

140
Q

if perirectal abscess involves an invasive infx and results in sub cut tissue necrosis what is tx

A

wide debridement for salvage; colostomy diversion to avoid further soilage to area and sequelae of fecal incontinence if sphincter is involved

141
Q

paronychia

A

staph infx of proximal fingernail that erupts at sulcus of the nail border

142
Q

tx paronychia

A

i/d, resection of portion of embedded nail, hot soaks

143
Q

felons

A

deep infx of terminal phalanx pulp space; occur after distal phalanx penetrating injuries and are tx by drainage; removal of nail may be necessary

144
Q

neglected infections of the fingers may result in

A

tenosynovitis; infx extends along tendon sheath

145
Q

organisms of bites human and animals

A

eikenella corrodens for humans and pasteurella for dogs/cats

146
Q

abx for biliary tract infx

A

cefazolin or cefoxitin

147
Q

mc inflammatory and infectious process in biliary tract

A

acute cholecystitis

148
Q

acute peritonitis

A

bacteria present within the normally sterile peritoneal cavity

149
Q

ct finding of peritonitis

A

upright chest roentgenogram commonly shows pneumoperitoneum beneath a hemidiaphragm with acute GI perforation and small amounts of pneumoperitoneum

150
Q

all pts w ulcer assoc perf should be assessed for presence of

A

helicobacter pylori

151
Q

abx for appendix

A

aerobic (e coli) and anaerobic (bacteroides fragilis) coverage

152
Q

cause and tx fungal infx

A

Candida; fluconazole, ketoconazole, miconazole, nystatin

153
Q

3 mc viral illnesses of concern for injury (needle stick)

A

hep B*, hep C, HIV

154
Q

A 32-year-old man is seen in the emergency department 45 minutes after a motor vehicle collision. His only injury is a long linear laceration beginning on the left temporal forehead at the hairline and extending posteriorly for 10 cm. The edges are still bleeding briskly and the EMTs described a large amount of blood at the scene. He did not lose consciousness. His last tetanus booster was 4 years ago. Which of the following is required for tetanus prophylaxis In this patient?

A. Tetanus immune globulin only

B. Nothing further at this time

C. Tetanus toxoid only

D. Tetanus immune globulin followed by a single tetanus toxoid booster

E. Tetanus immune globulin followed by three tetanus boosters

A

Answer: B

Wounds prone to the development of tetanus Include those with extensive contamination with soil, deep puncture wounds from metal objects, exposure Injury complicated with frostbite, and wounds >6 hours from time of Injury (Table 8-8.). Linear lacerations In general are not prone to tetanus. The extent of blood loss does not affect the need for tetanus booster administration. The patient last received tetanus toxoid

155
Q

A 48-year-old man Is being evaluated In the emergency department with fevers, chills, and abdominal pain for the past 24 hours. He has a history of hepatitis C infection following a blood transfusion 14 years ago for a large scalp laceration and orthopedic injuries sustained In a motor vehicle collision. He has not been to a physician for 5 years. He does not smoke or drink alcohol. He takes no medications. His temperature is 39°C and vital signs are: blood pressure (BP) 90/50 mm Hg, pulse 110/minute, and respirations 26/minute. A CT scan shows a single stone in the gallbladder that does not appear to be obstructing. The bile ducts are normal caliber and the gallbladder wall Is not thickened. There Is a moderate amount of fluid, mild small bowel distention, and stranding around the sigmoid colon as well as a small amount of free Intraperitoneal gas around the liver. An aspirate of the peritoneal fluid shows leukocytes and mixed Gram positives and negatives on Gram stain. Laboratory values show a WBC of 19,000/mm3, total bilirubin 1.2 mg/dL, and alkaline phosphatase 40 U/L. In addition to fluid resuscitation and broad-spectrum antibiotics, what is the best step in management?

A. Laparoscopic cholecystectomy

B. Long-term antibiotics only

C. Laparotomy

D. Magnetic resonance cholangiopancreatography (MRCP)

E. Endoscopic retrograde cholangiopancreatography (ERCP)

A

Answer: C

This patient has secondary peritonitis. This usually involves perforation of a hollow vlscus and thus involves contamination of the peritoneal cavity with multiple organisms. Gram stain and culture of the peritoneal fluid usually shows a single organism In patients with primary peritonitis and this can be treated with antibiotics without surgical Intervention. In this scenario, the CT scan shows stranding around the sigmoid and fluid and evidence of free air suggestive of a diverticulitis with fecal peritonitis. Patients with underlying liver disease are prone to gallstones and are a common finding. There Is no evidence of common bile duct obstruction that warrants further investigation since the alkaline phosphatase is normal.

156
Q

A 42-year-old woman Is seen In the infectious disease clinic because of a small laceration. She is a surgeon and was assisting a surgical resident with a colon resection when she was accidentally cut with a scalpel blade during the procedure. She has received all required Immunizations. Antibodies against which virus could be measured in order to assess the effectiveness of the only vaccine to prevent Infection potentially transmitted from the patient to the surgeon during the operative procedure?

A. Human immunodeficiency virus

B. Hepatitis C

C. Hepatitis B

D. Cytomegalovirus

E. Tuberculosis

A

Answer: C

HIV, hepatitis B, hepatitis C, and cytomegalovirus are transmitted by body fluids and blood; therefore, they pose an occupational risk to the surgeon. There Is currently a highly effective vaccine for the prevention of hepatitis B in the host. No such vaccine is available for the other viral Infections. Tuberculosis is not a virus but also poses a risk to health care workers.

157
Q

A 30-year-old man is in the hospital recovering from splenectomy for a ruptured spleen sustained in a motor vehicle collision. He has otherwise been healthy and was not taking medications prior to the injury. A temperature of 102°F Is noted on the second postoperative day. Vital signs are BP 130/80 mm Hg, pulse 100/minute, and respirations 18/minute. His pain is moderately controlled with morphine using patient-controlled analgesia (PCA). Breath sounds are diminished at both bases, more so on the left. His abdomen is mildly distended, soft and tender near the Incision. The incision appears to be healing without a problem. What Is the most likely cause for his fever?

A. Atelectasis and pulmonary infection

B. Peritonitis

C. Urinary tract Infection

D. Suppurative thrombophlebitis

E. Cardiac contusion

A

Answer: A

Early postoperative fever Is usually the result of atelectasis and subsequent pulmonary infection (Table 8-6). In this scenario, because of the close proximity of the left hemidiaphragm to the spleen, an Infiltrate In the left lower lobe of the lung Is a high probability. An adequately drained urinary tract In a young person seldom gives a high fever this early in the postoperative period. Although peritonitis from injury to a surrounding structure during the splenectomy (i.e., pancreas, stomach, or bowel) Is a possibility, It is much less likely than a pulmonary source. Cardiac contusion does not elicit a febrile response.

158
Q

A 25-year-old man is seen in the emergency department because of a painful swollen forearm. Two days ago, he sustained a small laceration to his left forearm while clearing brush. It caused only minor discomfort until about 12 hours ago when the area around the laceration became more red and swollen. He has otherwise been healthy. He takes no medications. His temperature Is 38°C. There is a 2-cm superficial laceration on the dorsum of his left forearm with 15-cm diameter surrounding erythema that is quite tender. The edges of the erythema were marked and 20 minutes later the erythema has extended another cm beyond the mark. The most likely causative organism is

A. methicillin-resistant Staphylococcus aureus.

B. β-Hemolytic Streptococcus A.

C. Escherichia coli.

D. Streptococcus faecalis.

E. Candida albicans.

A

Answer: B

Although cellulitis may be caused by any organism, the most likely early organism would be β-hemolytic Streptococcus A. methicillin-resistant Staphylococcus aureus more commonly causes local Inflammation and pus formation. The other three species are rarely isolated from skin infections but more commonly are seen In infections involving the gastrointestinal tract.

Surgery (21 decks)

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