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SurgicalInfection1/160DefinitionClassificationsEtiologyClinicalManifestationManagementSpecificSurgicalInfectionsCharacteristicsofHandInfectionsKeyPoints2/160Infections:PresenceoforganisminnormallysterilesiteaccompaniedbyaninflammatoryhostresponseInfectionsbetreatedbysurgicalinterventionInfectionsfollowingsurgicalprocedure(woundordistantsite)Definition3/160Non-specificinfectionFuruncle&CarbuncleCellulitis&ErysipelasHandinfectionAcuteappendicitisAcuteperitonitisBreastabscessClassifications：Characteristic4/160Classifications:CharacteristicSpecificinfectionTuberculosisFungalinfectionTetanusGasgangrene5/1606/160Acuteinfection(<3w)Mostnon-specificinfectionTetanusGasgangreneChronicinfection(>2M)TuberculosisSub-acuteinfection(3w-2M)UrinetractinfectionFungalinfectionClassifications：CourseofDisease7/160OpportunisticInfectionSuperinfectionNosocomialInfectionClassifications：Others8/160LocalphaseSkininfectionSoft-tissueinfectionHandinfectionAbscessSystemicphaseBacteremiaSepsisClassifications：Others9/160EtiologyofsurgicalinfectionPathogenicmicroorgansimLocalfactorsSystemicfactors10/160BacteriaVirusFungiEndotoxinEctotoxinEnzymeEtiology：PathogenicMicroorgansim11/160TraumaIschemiaandHypoxiaObstructionPresenceofForeignBodiesandNecroticTissuesIonizingRadiationEdemaEtiology：LocalFactors12/160ObstructionIschemiaTrauma13/160SevereTraumaDMCancer,ChemotherapyLeukemiaAIDSImmunodeficiencyMalnutritionEtiology：SystemicFactors14/160CureDisseminationAbscessformationBacteriamia&Sepsis&SIRS&MODSChronicinfectionResults：Non-specificInfections15/160MixedinfectionTuberculosisSystemicinfectionTetanus,gasgangreneOpportunisticinfectionFungiResults：SpecificInfections16/160ClinicalManifestationLocalizedsurgicalinfectionRednessSwellingPainHeatLossoffunction17/160FeverChillsTachycardiaLeukocytosis&leftshiftofWBCsClinicalManifestation18/160TachycardiaFeverFatigue19/160SynergisticGangrenecausedbystreptococci&staphylococci(self-injectionwithheroin)20/160Chill,FeverFlushingWarmExtremitiesMetastaticabscessShockinlatephaseSevereSystemicInfection(Gram-positive)ClinicalManifestation21/160

SevereSystemicInfection(Gram-negative)Chill,FeverColdExtremitiesShockinearlyphaseOliguriaHigh-outputheartfailureDisturbedsensoriumClinicalManifestation22/160HPIPhysicalExaminationGeneralConditionRegionalSymptomsMal-functionofRelatedOrgansCharacteristicManifestationsDiagnosis23/160Diagnosis：LabTestCBCCultureSensitivityTestOthersCTUltrasonicX-rayDiagnosis24/160Intravenouscannula---purulentdrainageorthrombophlebitisRectalexamination---pelvicabscessAuscultationofchest---pneumoniaPhysicalExam25/160AccumulationofextracellularfluidColor,odor,characterBeusefulincategorizingthecausativeorganismGramstainanessentialprocedurefordiagnosisandtreatmentPhysicalExam：Exudate26/160Breastabscess27/160BeingnecessaryfordiagnosissometimesEspeciallyforgranulomatousinfectionTuberculosisblastomycosisPhysicalExam：Biopsy28/160Operativeexploration&Biopsy29/160ExudatethemostreliablediagnosisfortreatmentBothaerobicandanaerobiccultureBloodDiagnosticstepforunknownsourceFailtocapturecausativeorganismsinbacteremiaUnnecessarytodiagnosesepsisSputumUrineCulture30/16031/160

GeneralSupportingTemperatureControlManagementofWaterandElectrolytesBalanceNutritionSupplementHypoalbuminemiaUderlyingFactorsVitalSignsMonitorManagement32/160ImmobilizationoftheinfectionareaEffectivelocalcareReliefofswelling&painProperDressingPhysicalTherapytoincreaselocalbloodsupplytofacilitateexudationManagement33/160SurgicalTherapyDebridementofInfectedornecrotictissuesHarboringforeignobjectsµorgnismsPoorbloodsupplyDecreasinghostresistanceSkinGraftingParacentesisDrainageofAbscessManagement34/160Simpleappendicitistreatedbyearlyoperation35/160Removingforeignbody36/160Neglected,perforatedappendicitiswithacomplexlowerabdominalabscessassociatedwithnecrosisofadjacenttissue37/160PrincipleofAntibioticsManagement38/160AcutesevertraumaandinfectionProphylacticManagementIndications39/160BacteriostaticagentsPreventgrowthofbacteria

BacteriocidalagentsActuallykillbacteriaManagement：Antibiotics40/160EffectiveagentagainsttheinfectingorganismAdequatecontactbetweenagentandorganismAbsenceoftoxicsideeffectoftheagentAugmentationofhostdefensestomaximizeantibacterialeffectsManagement：Antibiotics41/160CulturebeforeantibiotictherapyAdministerantibioticsonempiricbasisbeforethelaboratoryreportsCultureandsensitivitytest(Evidencebasis)acombinationofantibioticsforprobablepolymicrobicinfectionManagement：Antibiotics

42/160ColonizationThequantitativeappearanceofchangesinthemicroflorathatareinducedbyantibiotictherapySuperinfection

AnewmicrobialdiseaseintroducedorpotentiatedbyantibiotictherapySuperinfection

isfrequentlytheresultofcolonization.Colonization&Superinfection43/160forpotentiallycontaminatedwoundsOnlyanadjunctandNOTasubstitutetogoodsurgicaltechniqueAntibioticProphylaxis44/160CleanprocedurenoantibioticsarenecessaryCleancontaminatedprocedureContactoftheinteriorofrespiratory,urinary,GItractsContaminatedprocedureComplicatedbygrossspillageofintestinalcontentsorwoundssecondarytotraumaDirtywoundsIncontactwithintraabdominalorperirectalabscessAntibioticProphylaxis45/160MalnourishedObeseElderlyImmunodeficientShockorMOFPoorbloodsupplytotheoperativeregionAntibioticProphylaxis46/160earlyandenoughforadequatetissueandbodyfluidlevelsBeingnecessarytomaintainadequatetissuelevelsintra-operativelylengthofoperationandserumhalf-lifeofantibioticsAntibioticProphylaxis47/160CellularsiteofinhibitionBacteriocidalBacteriostaticCellwallsynthesispenicillincephalosporinsvancomycinBarrierfunctionofcellmembraneamphotericinBnystatinpolymyxinProteinsynthesisinribosomeaminoglycosidestetracyclinechloramphenicolErythromycinclindamycinDNAreplicationGriseofulvinAntibioticProphylaxis48/160SuperficialInfection49/160Staphylococci—G+betahemolysinsSuppurationandCharacteristicpusthick,yellow,withoutfoulsmellingS.aureus–furuncle&carbuncleS.epidermidis–aftersurgerywithforeignmaterialStaphylococcalInfection50/160ObesityDiabetesPoorhygieneconditionIntravenousdrugs

HighRiskFactors51/160Furuncle:characteristicFaceButtocksThighsGroinBreastAxilareaInfectioninvolvinganentirehairfollicleandtheunderlyingskintissue52/160<2cmraised,tender,shiny,brightredintense,throbbingpainyelloworwhitecreamydischarge(matured)Furuncle：Signs&Symptoms53/160AconfluentinfectioninvolvingmultiplecontiguousfollicleslimitedtothesubcutaneoustissuethickoverlyingskinanddensesubcutaneousfasciaCarbuncle：Characteristic54/16055/160BackofNeckorTorsoPain,swelling,indurationofthesurroundingskinMultiplesmallabscesswithyellowthickpasFever,fatigued,leukocytosis,evensepsisCarbuncle：Signs&Symptoms56/160Leisioncarehelpto“mature”

SurgicalincisiondrainageLarge&deepenoughincisionforcarbuncleAntibioticsPenicillinErythromycinClindamycinManagement57/160Management：Surgicaldrainage58/160goodhygieneconditionavoidingintravenousdruglooseclothingPrevention59/160Connectivetissuedermisandsubcutaneoustissuesacutespreadingpain,erythema,edema,andwarmthCellulitis：Characteristic60/160traumaorsurgerycausingalesionintheskinmayhavenodiscernibledermalinjurydevelopsoveraperiodofseveraldaysCellulitis：History61/160TheaffectedareaWarmthErythemaEdemaTendernessTheproximaltothearea

AscendinglymphangitislymphadenopathyCellulitis：Signs&Symptoms62/160SignificanterythemaAnerodedareanearthecenterIrregularmarginsbutnotraisedAnulceratedareainthecenterPainfulandwarmtothetouchSevereCellulitis：63/160normal

groupAstreptococci&StaphylococcusaureusInfantsgroupBstreptococciImmunocompromisedPneumococcusgram-negativerodsorfungiWoundsAeromonashydrophila,gram-negativerodEtiology：Microorganism64/160ObesityDiabetesPoorhygieneconditionIntravenousdrugsImmunodeficiencyHighRiskFactors65/160BacteremiaLocalabscessSuperinfectionwithgram-negativeorganismsLymphangitisThrombophlebitisFacialcellulitisinchildren(meningitisin8%)Gasgangrene(amputation&mortalityin25%)Cellulitis：Complications66/160EscherichiacoliinnephroticsyndromeCellulitisofthelowerextremitiesingeriatricpatients(thrombophlebitis)PseudomonadsinimmunocompromisedchildrenCellulitis：SpecialConcerns67/160Antibiotics:penicillinase-resistantsyntheticpenicillinfirst-generationcephalosporinclindamycinmetronidazoleManagement68/160causedbygroupAbeta-hemolyticstreptococciInvolvingdermisandlymphaticsmoresuperficialsubcutaneousinfectionthancellulitischaracterizedbyintenseerythema,induration,andasharplydemarcatedborder,Erysipelas：Characteristic69/16070-80%inlowerextremitiesErysipelas：Characteristic70/1605-20%infaceErysipelas：Characteristic71/160Abruptonsetofillness(Painfulrash)Initialfeverandchills(1-2dayslater)MuscleandjointpainNauseaHeadacheSystemicinfectiousmanifestationsSkindiscomfortErysipelas：History72/160FeverDermatologicsignsPainful,erythematous,andedematousrashSharply-raisedborderwithabruptdemarcationfromhealthyadjacentskinLymphangitis

Erythema(irregularextensions)DesquamationVesiclesLymphadenopathyErysipelas：Signs&Symptoms73/160Sharply-raisedborderwithabruptdemarcationfromhealthyadjacentskinErysipelas：Signs&Symptoms74/160PainfulErythematousEdematousrashErysipelas：Signs&Symptoms75/160GroupAstreptococci(themost)GroupG,C,Bstreptococci(less)Staphylococci(rarely)Etiology：Microorganism76/160Antibiotics(assoonaspossible)PenicillinErythromycinCephalexin

SymptomatictreatmentAntipyreticAnalgesicsHydration(oralintakeifpossible)ColdcompressesManagement77/160Gangrene&AmputationBacteremia&SepsisScarletfeverPneumoniaAbscessEmbolismMeningitisDeathComplications78/160Theinfectionoflymphnodes

(glands)usuallyassociatedwiththesiteoftheunderlyinginfection,tumor,inflammationcommonresultofacellulitisorotherbacteriainfectionLymphadenitis：Characteristic79/160swollen,tender,hardnodessmoothorirregulartotouchorsoftand"rubbery"(fluctuant)ifanabscesshasformedtheskinoveranodemaybereddenedandhotLymphadenitis：Signs&Symptoms80/160Infectionoflymphvessels/channelsCommonlyresultsfromcellulitisorabscess

intheskinorsofttissuesAprogressinginfectionraisingspreadofbacteriatothebloodstreamlife-threateninginfections

Be

confusedwitha

clotinavein(thrombophlebitis)Lymphangitis：Characteristic81/160redstreaksfrominfectedareatothearmpitorgrointhrobbingpainalongtheaffectedarealymphnodesfeverandchillsmalaise,lossofappetite,headache,muscleachesLymphangitis：Signs&Symptoms82/160PhysicalexaminationBiopsy(LN)BloodcultureLymphadenitisandlymphangitismayspreadwithinhours,spreadingtothebloodstreammaybefatal.Diagnosis83/160TreatmentshouldbeginpromptlySpecificantibioticsSurgicaldrainageHotmoistcompressesManagement84/160SurgicalSystemicInfection85/160SystemicInflammatoryResponseSyndrome(SIRS)systemicinflammatoryresponsewithoutevidenceofinfectionT,HR,RR,WBC86/160SystemicInflammatoryResponseSyndromeBeingmanifestedbyatleast2followings:T>38℃orT<36℃HR>90bpmRR>20bpmorPaCO2<32mmHgWBC>12023or<400087/160AsystemichostresponsesimilartosepsisThetriggerfortissueinjuryisnotbacterialtoxinsbutmassivetraumasuchasmechanicalinjuryorburnsSystemicInflammatoryResponseSyndrome88/160TNF,IL-1,IFN,LTIL-2,IL8,IL-12,IL-18,LTB4,GM-CSF,Chemokines,MIFIL-1ra,sTNFR,sIL-1RTGF,IL-4,IL-6,IL-10IL-11,IL13,PGE2,G-CSFantioxidants,IFN/89/160BacteremiaPositivebloodcultureofbacteriawithoutsystemicinflammatoryresponse90/160SepsisClinicalevidenceofinfection&systemicresponsetoinfection91/160SepsissyndromeSepsiswithhypoxia,elevatedlactate,oliguria,alteredmentalstatus92/16093/160CausesofSepsisSevertraumaSevereburnAcuteObstructiveSuppurativeCholangitisAcutediffusedperitonitisCatheter-relatedinfectionGutderivedinfection94/160RisksFactorsofSepsisImmunocompromisedpatientsMorefrequentuseofinvasivedevicesorprocedureGreateravailabilityoflife-sustainingtechnologyHigherfrequencyofinfectionscausedbyresistantorganismsAgingpopulation95/160DistributionofSepsisGram-NegativeSepsis——57%Gram-PositiveSepsis——40%FungiSepsis——3%96/160Signs&SymptomsofSepsisPrimaryFeverChillsHyperventilationSkinlesionsChangeinmentalstatus97/160

HypotensionBleeding&Leukopenia&ThrombocytopeniaCyanosis&AcidosisOliguia&AnuriaCongestivefailureJaundiceComplication98/160BacteriaofGram-negativeSepsisFrequencyMortaliyE.ColiPseudomonasKlebsiella）KlebsiellaPseudomonasProteusSerratiaE.ColiEnterobacterSerratiaProteusEnterobacter99/160Gram-negativesepsis100/160Endotoxin101/160G(+)sepsisG(-)sepsisbacteriaS.aureusE.ColiPseudomonastoxinexotoxinendotoxinPrimarysitescarbuncle,cellulitis,burnbiliary,uriary,GI,burnchillseldomcommonfeverlastinghighhighorlowskinlesioncommonseldomchangesinCNScommonseldomHypoxia&CyanosisseldomcommonoliguriaseldomcommonshockseldomcommonSecondarymyocarditiscommonseldomsecondaryabscesscommonseldom102/160CharacteristicsofFungalSepsisTheresultofopportunisticinfectionafterbroad-spectrumantibioticstherapyCandidaalbicansisthecommonestpathogenChill,fever>39.5℃,changeinmentalstatus,hypotension,shockWBC>25,000/dl103/160Mortality&PrognosisofSepsisClinicalsignsMortalityrateFever,Leukocytosis10%MultipleOrganFailure64%Shock69%ShockwithMOF88%Total42%104/160TreatmentofSepsisDebridementofprimaryinfectionAntibioticstherapySupportive&MiscellaneousTherapy105/160Supportive&MiscellaneousTherapyRecoveryofenteralnutritionaspossibleCorrectionofacid-basis&electrolytebalanceDiureticsNaloxoneCorticosteroidsTransfusionofleukocyteconcentrateImmunotherapy106/160ResultedfromexotoxinproducedbyC.tetaniaseverediseaseprimarilyofolderadultswhoareunvaccinatedorinadequatelyvaccinatedCharacterizedbyhypertonia,painfulmuscularcontractions,musclespasmsTenanus107/160ClostridiumtetaniAnobligateanaerobicgram-positivebacillusFormationofsporeswhichareresistanttoheat,desiccation,anddisinfectantsBeingubiquitousinsoil,housedust,animalintestines,andhumanfecesEtiology108/160AnimalbitesBurnsChronicotitisCrushinjuriesDentalproceduresElectivesurgicalabrtionFrostbitewoundsHumanbitesPuncturewoundsSurgeryCommonsources109/160MedianIncubationperiod=7days73%=4-14days15%=<4days12%=>14daysclinicalmanifestationsoccurringwithin1weekofaninjuryhavemoresevereclinicalcoursesMildpenetratingwoundevenbehealedbeforetoxindevelopmentIncubationPeriod110/160ArrhythmiasComaDifficultybreathingDifficultyswallowingHighbloodpressureIrritabilityNeckpain&stiffnessRestlessnessSeizuresClinicalManifestation111/160Trismus(lockjaw)—75%Pain&Stiffness(neck,back,abdomen)DysphagiaRestlessnessReflexspasms.“Risussardonicus”expressionClinicalManifestation:112/160Trixmus/lockjaw113/160Risussardonicusexpression114/160Neckpain&stiffness115/160Opisthotonus116/160Seizures117/160Coma118/160WoundManagementTATTetanusvaccine(DPT)Tetanusimmuneglobulin(forhigh-riskwoundsorpersonwhohasneverbeenimmunizedinjections)Prevention119/160toremovenecrotictissueandforeignbodiestocreateanaerobicenvironmentSurgicaltherapy120/160AnticonvulsantsValiumLuminalSkeletalmusclerelaxantsBaclofenDantroleneAntitoxinsTetanusimmuneglobulinsMedications121/160AntibioticsPenicillinGTetracyclineNeuromuscularblockingagentsVecuronium

Medications122/160Overallmortalityisapproximately45%IntheUnitedStatesmortalityrateis6%(previouslytetanustoxoid)mortalityrateis15%(unvaccinatedindividuals)Mortality123/160MostpeoplerecoverfromtetanuscompletelyRecoveryfrom2to4monthsSomeindividualshavelowmuscletoneafterrecovery.Prognosis124/160HandInfection125/160AnatomyfactorsMultiplecompartmentsandplanesinhandInfectionsaredictatedbyfascialboundariesinhandBackground126/160ParonychiaFelonTenosynovitisDeepfascialspaceinfectionsClassifications：Characteristic127/160ThelateralnailfoldStartingasacellulitis,progressiontoabscessformationEponychia(spreadstotheproximalnailedge)Paronychia：Characteristic128/160RecenttraumatolateralnailfoldNailbitingManicuringDishwashingFingersucking（children）Paronychia：history129/160Edema,Erythema,PainalonglateraledgeofnailfoldMayhaveextensiontoproximalnailedge(eponychium)PossibleabscessformationParonychia：Signs&Symptoms130/160Staphylococcus&StreptococcusinmostcasesMycobacteriaandfungiinchroniccasesorimmunocompromisedpatientsAnaerobesinthepediatricpopulationduetofingersucking.Etiology：Microorganism131/160Ifnofrankabscessfrequenthotsoaks&antibiotics

IfpusispresentincisionanddrainageIfpushastrackedbeneaththenailremoveanadjacentlongitudinalsectionIfeponychiaisresultedremovetheentirenailplateManagement132/160133/160134/160135/160Eponychia(Subungualabscess)OsteomyelitisofthedistalphalanxDevelopmentofafelonChronicinfectionComplications136/160Mostresolvein2-4daysChronicinfectionsarelikelyfungalinfections.Prognosis137/160TheinfectionofdistalpalmarphalanxFelon：Characteristic138/160CompartmentalizedinfectionIncreasedpressurewithintheclosedcompartmentImpairedvenousoutflowalocalcompartmentsyndromeandmyonecrosisandosteomyelitisFelon：Characteristic139/160Staphylococcus&Streptococcus

isthemostcommoncausativeorganismTypicallydirectinoculationofbacteriabypenetratingtraumaMaybecausedbyhematogenousspreadLocalspreadfromanuntreatedparonychiaEtiology：Microorganism140/160RecenttraumatofingerpadorparonychiaTypicallyThrobbingPainSwelling,Pressure,ErythemaFelon：Signs&Symptoms141/160Painful,Tense,ErythematousfingerpadPointingofabscesspossiblypresentSignstypicallylimitedtoareadistaltothedistalinterphalangealjointEvidenceofpenetratingtraumaFelon：Signs&Symptoms142/160Frankabscess&tensefingerpadistheindicationAlongitudinalincisionovertheareaofgreatestfluctuanceToavoidpenetrationofthetendonsheath,theincisionshouldnotextendtothedistalinterphalangealcreaseUsingahemostat,bluntlydissectthewoundtopromotedrainageIrrigatingthecavitycopiouslyandlooselypackwithagauzewick.Incision&Drainage143/160scarringsensorylossunnecessarypaininstabilityofthefingerpadspreadofinfectionintotheadjacenttendonsheath.Incision&Drainage144/160145/160Reevaluatethewound48hoursafterinitialincisionIfcontinueddrainageispresent,looselyrepackthewoundIfnofurtherdrainageispresent,repackingisunnecessaryContinueantibioticsfor5-7daysTh