Wound infection

WOUND INFECTION

COLLEGE OF DENTISTRY2012-2013

GENERAL PATHOLOGY

HISTORYWINE &VINEGAR;USED AS ANTISEPTIC TO CLEANTHE WOUNDS.MAGIC BULLET:IT IS THE CONCEPT OF PRODUCTIO-N OF A CHEMICAL WHICH KILLS MICRORGANISMCELL AND SPARING THE AFFECTED HUMAN CELLS.FIRST ANTIMICROBIAL DISCOVERED IS SULPHANA-MIDES,THEN PENICILLINS.INSPITE OF GREAT ANTIMICROBIALS MANUFACTU-RED ,SOME BACTERIA PRODUCING SPECIAL ENZY-ME THAT DESTROY THE ANTIMICROBIALS.

CONT,D MOST OF ANTIMICROBIALS HAVE BETA LACT-AM RING WHICH IS DESTROYED BY AN ENZYMECALLED BETA LACTAMASE PRODUCED BY SOMEBACTERIA.TO PREVENT INFECTION BETTER THAN TO TREAT ITi.e. PROPHYLAXIS.1-ASEPTIC TECHNIQUES.2-ANTIBIOTICS PROPHYLAXIS ,BEFORE ,DURING AND AFTER SURGERY.3-DELAYED CLOSURE OF A CONTAMINATED WOUND IS A SAFE VALVE TO PREVENT INFECTION.

BODY RESISTANCE TO INFECTION--MECHANICAL:SKIN,MUCOUS MEMBRANE INTIGRITY.--CHEMICAL:LIKE ACIDITY IN THE STOMACH. SKIN SECRAETIONS TO KILL SOME ORGANISMS.---HUMORAL:OPSONIN,COMPLEMENT SUBSTANCE.---CELLULAR:MACROPHAGE,POLYMORPHS.

WOUND INFECTIONDEFINTION:IT IS INVASION OF MICRORGANISM THR-OUGH TISSUE AFTER BREAKDOWN OF LOCAL AND/OR SYSTEMIC HOST DEFENCE ,WITH PRODUCTIONOF LOCAL INFLAMMATORY REACTION.WOUND INFECTION COULD BE AT THE TIME OF INJU-RY OR LATER ON.IT DEPENDS ON HOST RESISTANCE,AND VIRULENCE OF THE MICRORGANISM.

PATHOLOGICAL &CLINICAL CONDITIONS RELATED TO INFECTION

INFECTION:LOCAL INFLAMMATION DUE TO INVASIONOF VIRULENT MICRORGANISM.

SEPSIS:IT IS LOCAL INFECTION + SYSTEMIC MANIFEST- ATIONS –SYSTEMIC INFLAMMATORY RESPONSE

SYNDROME (SIRS).

SIRS WHEN 2 OR MORE OF THE FOLLOWINGS PRESENT: -TEMPERATURE=MORE THAN 38 OR LESS THAN 36

DEGREE CENTIGRADE. -W.B.C. MORE THAN 12,000 OR LESS THAN 4,000.

CONT,DPULSE RATE:MORE THAN 90/MINT.RESPIRATORY RATE:MORE THAN 20/MINT.THE PATHOGENESIS OF SIRS IS REALEASE OF CYTOKIN-ES (INTERLEUKINS,TUMOR NECROSIS FACTOR -TNF) FROMMACROPHAGES AND NEUTROPHILS.SIRS COULD BE SEEN IN MULTIPLE TRAUMA,BURN,ACUTE PANCREATITIS,IN ADDITION TO SEPSIS .

SEVER SEPSIS:SEPSIS+ MODS(MULTIPLE ORGAN DYSFUNCTION SYNDROME),ONE OR MORE ORGAN DYSFUNCTION.LIKE ARDS (ACUTE RESPIRATORY SYNDROME),,RENAL(ACUTE TUBULAR NECROSIS), HEPATIC (COAGULATION ABNORMALITY&HYPERBILIRUBINAEMIA).

AGAIN THESE EFFECTS DUE TO RELEASE OF INTERLEUKINS&TNF.

CONT,DSEPTIC SHOCK:SEVER SEPSIS + HYPOTENSION ANDEND IN MSOF(MULTIPLE SYSTEMIC ORGAN FAILURE). DEFINITION OF INFECTED STATES IN SUMMARY:SSSI :IT IS WOUND INFECTION.SIRS :BODY SYSTEMIC RESPONSE TO INFECTION.MODS:EFFECT OF INFECTION ON WHOLE BODY .MSOF: END STAGE OF UNCONTROLLED MODS.

RISK FACTORS INCREASING RISK OF INFECTION

LOCAL FACTORS:1-POOR BLOOD FLOW LIKE ATHEROSCLEROSIS.2-FOREIGN BODY.3-POOR SURGICAL TECHNIQUE:DEAD SPACE,HAEMATOMA,TOO

MUCH DISSECTION WITH DEVASCULARISATION.GENERAL FACTORS:1-AGE .2- MALNUTRITION.OBESITY,HYPOPROTEINAEMIA,ANAEMIA.3-METABOLLIC:URAEMIA,JAUNDICE,DIABETIS MELLITUS.4-IMMUNE

DEFCIENCY:AIDS,CANCER,CHEMOTHERAPY,RADIOTHERAPY OR STEROIDS THERAPY.

OPPORTUNISTIC INFECTIONIT IS INFECTION BY AVIRULENT MICRORGANISM,WH-EN THE BODY RESISTANCE ,OR DEFENCE SYSTEM,IS COMPROMISED ,OR BROKEN AS IN SEVER BURN,AIDS,OR PATIENT ON IMMUNOSUPPRESSION

THERAPY(RENAL TRANSPLANT),STEROIDS OR CHEMOTHERAPY.

RATES OF SURGICAL WOUND INFECTION TYPES OF WOUNDS ACCORDING TO THE RATES OF

INFECTION:1- CLEAN WOUND:LIKE HERNIA SURGERY,THYROID, BREAST SURGERY —RATE OF INFECTION 1%-2% .2-CLEAN CONTAMINATED:LIKE CHOLECYSTECTOMY, ORAL CAVITY,GASTRIC SURGERY,BOWEL SURGERY. RATE OF INFECTION LESS THAN 10% .3-CONTAMINATED:APPENDICECTOMY, DIVERTICULITIS RATE OF INFECTION 15%-20%4-DIRTY WOUND: PUS DRAINAGE IN PERFORATED APPENDICITIS,APPENDICULAR ABSCESS,APICAL ABSCESS. RATE OF INFECTION IS LESS THAN 40% .

SOURCE OF INFECTION1-PRIMARY—ENDOGENOUS FROM THE PATIENT OR COMMUNITY ACQUIRED.2-SECONDARY—HOSPITAL ACQUIRED—NOSOCOMIAL INFECTION-FROM THE THEATRE OR THE WARD.

SURGICAL SITE INFECTIONSUPERFICIAL SURGICAL SITE INFECTION: SKIN & SUBCUTANEOUS TISSUE.

DEEP SURGICAL SITE INFECTION: MUSCLE & FASCIA.

ORGAN OR SPACE SURGICAL SITE INFECTION: ABDOMINAL OR THORACIC (COELOMIC CAVITY).

SURGICAL SITE INFECTION (SSI )

SSSI

SURGICAL WOUND INFECTIONOTHER CLASSIFICATION OF SURGICAL SITE INFECTION, (SSI) :MINOR INFECTION-SIMPLE INFECTION WITHOUT SIRS. AND PATIENT DISCHARGED HOME.MAJOR INFECTION—INFECTION WITH EXCESS OF PUS, AND WITH SIRS,AND KEEP PATIENT IN THE HOSPITAL,FOR FURTHER TREATMENT.

SURGICAL WOUND INFECTIONMINOR WOUND INFECTION—NO,SIRS MAJOR WOUND INFECTION-TOO MUCH PUS +SIRS

TYPES OF INFECTION1- WOUND ABSCESS.2- CELLULITIS & LYMPHANGITIS.3- BACTERAEMIA & SEPTICAEMIA.4-SPECIFIC WOUND INFECTION :GAS GANGRENE.

WOUND ABSCESSIT IS PUS CONTAINING CAVITY .ACUTE ABSCESS: THE WALL OF THE ABSCESS, (CALLED

PYOGENIC MEMBRANE);IT IS COMPOSED OF INFLAMMED TISSUE AND FIBRIN ,HEAVILY INFILTERATED BY POLYMORHS ,MACROPHAGE.

CHRONIC ABSCESS: WHEN THE WALL COMPOSED OFFIBROUS TISSUE AND HEAVILY INFILTERATED BY,POLY-MORPHS,MACROPHAGE AND OTHER CHRONIC

INFLAMMATORY CELLS (LYMPHOCYTES&PLASMA CELLS).

SURGICAL WOUND INFECTIONWOUND INFECTION-PUS COLLECTION INFECTION WITH CELLULITIS

WHAT IS PUS,AND PUS CELLS?PUS IS A FLUID COMPOSED OF :DEAD &DYING WBC,DEAD &DYING BACTERIA(IN BACTERIAL CAUSE OF

PUS),TISSUE DEBRIS,OEDEMA,FIBRIN,LIPID AND NUCLEIC ACID.

PUS CELLS :IT IS DEGRANULATED WBC NEUTROPHILS.ACUTE ABSCESS APPEARS 7-9 DAYS AFTER SURGERY ,OR TRAUMA.IF NOT DRAINED IT MIGHT RUPTURE,LEADING TO DISCHARGING SINUS.CHRONIC ABSCESS:IT IS EITHER FROM ACUTE INFECTION AND NOT DRAINED AND PRESENCE OF FOREIGN

BODY OR DEAD TISSUE.IT MIGHT BE FROM THE START CHRONIC AS IN T.B. & ACTINOMYCOSIS.

MANAGEMENT OF ABSCESSDIAGNOSIS:-CLINICAL: PYREXIA,HIGH PULSE,LEUCO-CYTOSIS.IMAGING TESTS:U/S,CT SCAN &MRI.TREATMENT:DRAINGE UNDER COVER OF ANTIBIOTICS,S.T. ASPIRATION UNDER U/S OR CT GUIDE.NO, CLOSURE OF ABSCESS CAVITY AFTER DRAINAGE,LEAVE IT FOR SPONTANEOUS CLOSURE,OTHER WISE,IT WILL RECURE.

SURGICAL WOUND ABSCESSREMOVAL OF STICHES—DRAIN ABSCESS--LEAVE IT

OPENEDFOR DELAYED PRIMARY SUTURING OR

SECONDARY SUTURING

IMAGING TO DIAGNOSE DEEP ABSCESSU/S ABSCESS CAVITY SPLENIC ABSCESS SHOWN BY CT SCAN

ASPIRATION OF THE ABSCESS UNDER U/S & CT SCAN

DRAINAGE OF ABSCESS DRAINAGE UNDER IMAGING SURGICAL DRAINAGE

CELLULITIS,LYMPHANGITISCELLULITIS:DIFFUSE ,NON-LOCALISED NON-SUPPURATATIVE INFLAMMATION CAUSED BY MICRORGANISMSTHAT PRODUCE ,CERTAIN ENZYMES WITH DIFFUSETISSUE DESTRUCTION.THESE ENZMES

ARE,STREPTOKINASE ,HYALURONIDASE & OTHER PRO- TEASE ENZYMES,LYSING TISSUE BARRIERS.THE COMMON CAUSATIVE ORGANISM :BETA-HAEMOLYTIC STREPTOCOCCI.CLUSTRIDIA PERFERINGENS.STAPHYLOCOCCI.THIS CELLULITIS ASSOCIATED WITH SIRS,DUE TO RELEASEOF CYTOKINES(INTERLEUKINS,TNF),FROM MACROPHAGE

&POLYMORPHS.

CELLULITSDIFFUSE NON-LOCALISED INFLAMMATION NON-SUPPURATIVE INFLAMMATION

CELLULITISFACIAL CELLULITIS ORBITAL CELLULITIS

LYMPHANGITIS IT IS NON-LOCALISED DIFFUSE INFLAMMATION OF

LYMPHATIC CHANNELS COMMONLY CAUSED BY STREPTOCOCCUS PYROGENES (BETA HAEMOLYTIC STREPTOCOCCI),PRODUCING RED PAINFUL STREAKS IN THE AFFECTED LYMPHATICS WITH PAINFUL LYMPH NODE ENLARGEMENT.

LYMPHANGITISRED PAINFUL STREAKS AXILLARY L.N. ENLARGMENT

OTHER FORM OF INFECTION----BACTERAEMIA,SEPTICAEMIA,PYAEMIA

DEFINITION:BACTERAEMIA :TRANSIENT PRESENCE OFBACTERIA IN THE BLOOD CIRCULATION CAUSING FEWSYMPTOMS,LIKE RIGOR.THAT WHAT HAPPENS AFTERURINARY BLADDER CATHETERISATION IF SOME INFEC-TION THERE,OR AFTER EXTRACTION OF TOOTH WHICH HAS APICAL

ABSCEES.BACTERAEMIA EASILYCONTROLLED BY BODY MPS(MONONUCLEAR PHAGOCYTESYSTEM).PATIENT WITH GOOD IMMUNITY. THE PROBLEM IN THIS CONDITION IS PATIENT WITH C.H.D.,VALVULAR HEART DISEASE,VALVE REPLACEME- NT,JOINT REPLACEMENT,SO BACTERIA WILL SETTLE IN THE HEART

PRODUCING SUBACUTE BACTERIAL ENDOC-CARDITIS ,BY STREPTOCOCCI VIRIDANS OR JOINT INFECTION.

TYPES OF INFECTION—CONT,DPYAEMIA:INFECTED THROMBUS CIRCULATING IN THE

BLOOD,PRODUCING METASTATIC ABSCESS.

e.g.;ACUTE APPENDICITIS,INFECTED PILES LEADTO PORTAL PAEMIA LEADING TO METASTATICLIVER ABSCESS.ACUTE SUPPURATIVE ARTHRITIS,OR ACUTEOSTEOMYLITIS MIGHT LEAD TO PYAEMIA WITHMULTIPLE LUNG ABSCESS.

CONT,D SEPTICAEMIA:THE ORGANISM PROLIFERATES &BL- OOD FLOODED WITH THE ORGANISM AND THE MPS UNABLE TO DESTROY THEM,SO PATIENT, GRAVELY ILL ,POOR RESISTANCE WITH SEVER

CONSTITUTIONAL SYMPTOMES LEADING TO SEPTIC SHOCK AND EVEN TO MSOF(MULTIPLE SYSTEM ORGAN FAILURE ) LEADING TO IRRIVERSIBLE SHOCK AND DEATH.MAIN ORGANISMS INVOLVED IN BOTH BACTERAEMIA & SEPTICAEMIA,GRAM NEGATIVE AEROBIC INTESTINAL BACILLI,

(E.COLI,PROTEUS,KLIBSIELA,PSUDOMONAS). STAPHYLOCOCCI,AND FUNGI MIGHT BE INVOLVED.SEPTICAEMIA OCCURS AFTER BOWEL SURGERY,BURNS.

WHAT IS THE DIFFERENCE BETWEEN BACTERAEMIA &SEPTICAEMIA ?

BACTERAEMIA SEPTICAEMIA

OTHER TYPES OF WOUND INFECTIONSPECIFIC WOUND INFECTION; GAS GANGRENE:IT IS INFECTION BY GRAM POSITIVE ANAEROBIC SPORE-

FORMING BACILLI,(CL.PERFRINGENS), DUE TO CONTAMINATION OF THE WOUNDS BY FAECES,OR SOILS,COMMONLY SEEN

DURING WAR AND TRAUMATIC SURGERY,PARTICULARLY IN ATHEROSCLROSIS LIMBS OR CLOSED DIRTY

WOUNDS (ANAEROBIC ENVIROMENT),SO NEVER CLOSE THE WOUND.ALSO DIABETICS,OR IMMUNOCOMPROMISED ARE AT HIGH

RISK.AMPUTATED LIMB IN ATHEROSCLEROSIS IS AT RISK. THE CHARACTERISTICS OF THE WOUND IS PAINFUL WITH CREPITUS DUE TO GAS WHICH SEEN BY X-RAY BROWN SWEET SMELLING EXUDATE WITH OEDEMATOUS, SPREADING GANGRENE,PATIENT WITH CIRCULATORY COLLAPSE, SEPTIC SHOCK & MSOF. ACUTE HAEMOLYTIC ANAEMIA DUE TO ALPHA TOXINS. TREATMENT:EXTENSIVE AGGRESSIVE WOUND EXCISION WITH HEAVY DOSE OF PENICILLIN.

CLOSTRIDIUM PERFRENGENSGRAM POSITIVE ANAEROBS WITH SPORES SUBTERMINAL SPORES

GAS GANGRENEBLISTER WITH GAS FORMING BACTERIA ATHEROSCLEROTIC AMPUTATED LIMB

OTHER INFECTION BY CLOSTREDIA TETANUS :CAUSED BY CLOSTRIDIA TETANTI,GRAM

POSITIVE ANAEROBIC,SPORFORMING BACILLI,HAVE THE EFFECT DISTANT FROM THE WOUND BY 2

EXOTOXINS:TETANOSPASMIN ATTACK CNS,TETANO LYSIN TO HAEMOLYSE RBC . IT CAUSES NEUROLOGICAL DISORDER LIKE

OPISTHOTONUS,RISUS SARDONICUS,RESPIRATORY FAILURE IS THE MAIN CAUSE OF DEATH.

PROPHYLAXIS :TOXOID VACCINATION,AND GAMMA GLOBULIN THERAPY.

CLOSTRIDIUM TETANI-DRUM STICK LIKE BACILLI

TETANUSFACIAL & BODY MUSCLE TONIC CONTRACTION RISUS SARDONICUS

OPISTHOTONUS-TONIC CONTRACTION OF THEMUSCLES OF THE BACK

OTHER INFECTION—SYNERGISTIC SPREADING GANGRENE

IT IS AN INFECTION CAUSED BY MIXED ORGANISM ACTING SYNERGISTCALLY,STAPHYLOCOCI,ANAEROBIC STREPTOCOCCI,BACTEROIDS,&COLIFORM,PRODUCI-NG DIFFUSE GANGERNOUS ABDOMINAL WALL,

PARTICULARLY AFTER PERITONITIS DRAINAGE, ASSOCIATED WITH CIRCULATORY COLLAPSE,AND EVEN MSOF IT IS ALSO CALLED ,NECROTISING FASC- IT IS ,(MELENY,S SYNERGISTIC GANGRENE ). TREATMENT:CIRCULATORY SUPPORT +WIDE LOCAL

EXCISION + ANTIBIOTICS .

SYNERGISTIC GANGRENE

CONCRUM ORIS—GANGRENOUS STOMATITIS-SYNERGISTIC INFECTION-OPPORTUNISTIC INFECTION-LEUKAMIA

A WOUND BECOMES INFECTED OR NOT DEPENDS ON

1-VIRULENCE OF THE MICRORGANISM.2-DOSE OF THE MICRORGANISM.3-VASCULARITY OF THE TISSUE INVADED.4-HEALTH OF THE TISSUE INVADED.5-PRESENCE OF DEAD TISSUE OR FOREIGN BODY.6-GENERAL HOST DEFENCE SYSTEM.7-USE OF PROPHYLACTIC ANTIBIOTICS. PROPHYLACTIC ANTIBIOTIC SHOULD BE GIVEN PREO- PERATIVELY OR AT THE TIME OF CUTTING AS THE BACTERIA

INVADES THE BODY AND THE HOST NEEDS 4 HOURS (DECISIVE PERIOD) TO DEFEND(HUMORAL &CELLULAR RESISTANCE),SO ANTIBIOTIC SHOULD BE GIVEN AT THE TIME MENTIONED ABOVE.

PYOGENIC INFECTION INFECTION BY MICRORGANISM WITH PUS FORMATION

OR SUPPURATION. COMMONEST ORGANISMS INVOLVED IN WOUND INFECTION ARE:STAPHYLOCOCCI,STREPTOCOCCI,GRAM

NEGATIVE AEROBIC INTESTINAL BACILLI (E.COLI,PROTEUS, KLEBSIELA,PSEUDOMONAS) AND ANAEROBIC GRAM NEGATIVE INTESTINAL BACILLI –BACTEROIDS.

WHEN MICRORGANISM INVADES THE WOUND,LEADSTO ACUTE INFLAMMATION---RESOLUTION,IF

NOT,SUPPURATION,IF NOT DRAINED –DISCHARGING SINUS.IF NOT RESOLVED ---CHRONIC INFLAMMATION,

LIKE CHRONIC CHOLECYSTITIS,CHRONIC OSTEOMYLITIS.

GENERAL BODY RESPONSE TO INFECTION--PYREXIA.---RAPID PULSE.---LOSS OF WEIGHT.--- INCREASE OF W.B.C. COUNT.----HIGH ESR.

GENERAL TREATMENT OF WOUND INFECTIONIN MINOR WOUND INFECTION,NO,WORRY SENDPATIENT HOME.IN MAJOR WOUND INFECTION WITH PUS COLLECTION:REMOVE

THE STICHES,DRAIN THE ABSCESS,SWAB THE PUS,SEND FOR CULTURE &

SENSITIVITY TEST FOR AEROBIC &ANAEROBIC MIC- RORGANISM,MEAN WHILE START EMPERICAL ANTIBIOTICS

WHILE WAITING FOR THE RESULT OFC&S TEST.IF PATIENT IMPROVING KEEP ON THE ANTIBIOTIC

ALREADY STARTED,IF NO,IMPROVEMENT SHIFT TO THE RESULT OF C& S TEST.

ANY ABSCESS SHOULD BE DRAINED AND LEFT OPENED,TILL CLEARANCE THEN IF NOT CLOSED SPONTANEOUSLY,DO DELAYED PRIMARY SUTURING(4-6

DAYS).OR SECONDARY SUTURING (10-14 DAYS.) .

BACTERIA INVOLVED IN WOUND INFECTIONSTREPTOCOCCI:GRAM POSITIVE AEROBIC COCCI.Streptococcus pyogens---CELLULITIS.Streptococcus faecalis---ENTEROCOCCI,INVOLV- ED IN WOUND INFECTION AFTER BOWEL SURGERY.Streptococcus viridans---SUBACUTE BACTERIAL

ENDOCARDITIS –AFTER BACTERAEMIA.SENSITIVE TO PENICILLIN & ITS DERIVITIVES.SENSITIVE TO AMPICILLIN, & AMOXOCILLIN.

STREPTOCOCCISTREPTOCOCCI—CHAIN COCCI CELLULITIS

BACTERIA INVOLVED IN WOUND INFECTION-CONT,DSTAPHYLOCOCCI :GRAM POSITIVE,AEROBIC COCCI.INFORM OF CLUSTERS.COMMONEST CAUSE OF SURGIC-AL WOUND INFECTION PRODUCING LOCALIZED PUSFORMATION.Staphylococcus aureus :COAGULASE POSITIVE, ITMEANS PRODUCING ENZYME TO MAKE THE INFECTI-ON ,MORE LOCALISE BY FIBRIN FORMATION.THESE BACTERIA PRODUCING BETA LACTAMASE ,WHICH DESTROYS THE BETA RING OF PENICILLIN SUB-STANCE.IT IS SENSITIVE TO :FLUCLOXACILLIN,VANCOMYCIN,AMIN-OGLYCOSIDES(GENTAMYCIN),THIRD GENERATION CEPHA-LOSPORINS(CEFATOXIME & CEFATRIOXONE).

STAPHYLOCOCCICLUSTERS OF STAPH STAPHYLOCOCCAL WOUND INFECTION

WHAT IS MRSA ?

IT IS TYPE OF STAPHYLOCOCCI RESISTANCE TO ANTI-BIOTIC METHICILLIN AND HAVE THE ABILITY TO PRODUCE EPIDEMIC INFECTION SPREDING IN THE HOSPITALAND IT IS SENSITIVE TO ANTIBIOTIC VANCOMYCIN.

WHAT IS VRSA?IT IS VANCOMYCIN RESISTANT Staphylococcus aureusAGAIN PRODUCING SPREADING HOSPITAL INFECTIONBUT SENSITIVE TO TEICOPLANIN AND LINEOZOLID

ANTIBIOTICS.

OTHER BACTERIA PRODUCING WOUND INFECTIONCLOSTREDIA;

Clostridium perfrengens; GRAM POSITIVE SPORE FORM-ING ANAEROBIC BACILLI CAUSING GAS GANGRENE.PENICILLINE OR METRONIDAZOLE ANTIMICROBIALS.Clostridium tetani:CAUSING TETANUS.Clostridium difficile:CAUSING PSEUDOMEMBRANOUS COLITIS WITH SEVER DIARRHEA AS ARESULT OF LONGUSAGE OF SPECIAL ANTIBIOTICS LIKE CLINDAMYCIN,& LINCOCIN.TREAMENT VANCOMYCIN,OR

METRONIDAZOLE(FLAGYL).

GRAM NEGATIVE INTESTINAL BACILLITHESE NORMAL BOWEL INHABITANTS.AEROBIC GROUP:E.COLI,PROTEUS,KLEBSIELA,PSEUDOMONAS.ANAEROBIC GROUP:BACTEROIDS;IT PRODUCES FOUL ODOR PUS,TYPICALANEROBIC INFECTION.AEROBIC+ANAEROBIC=MIXED PRODUCING WOUND INFECTION AFTER BOWEL SURGERY,LIKE

APPENDICECTOMY,DIVERTICULITIS,PERITONITIS.PSEUDOMONAS IS IMPORTANT IN BURN

INFECTION,AND SEPTICAEMIA.ALSO INFECTION OF TRACHEOSTOMY.

GRAM NEGATIVE INTESTINAL BACILLI THE AEROBIC GROUP SENSITIVE TO THE

ANTIBIOTICS; AMINOGLYCOSIDES(GENTAMYCIN),SECOND

GENERATION CEPHALOSPORINS(CEFAFUROXIME), QUINOLONES (CIPROFLUXACIN). CARABPENEM(MEROPENEM). PSEUDOMONAS:ARE RESISTANT BACTERIA BUT

STILL SENSITIVE TO :AZLOCILLIN,CEFTAZIDIME(THIRD GEN-

ERATION CEPHALOSPORINS). TAZOCIN INJECTION: TAZOBACTAM +PIPERACILLIN.

SURGICAL WOUND INFECTION AFTER BOWEL SURGERY

THE WOUND OPENED TO DRAIN THE PUS COLLECTION

BURST ABDOMEN AFTER BOWEL SURGERY INFECTION

BACTERIA INVOLVED IN WOUND INFECTION& ANTIBIOTICS AFFECTING THEM—CONT,D

LACTMASE PRODUCING BACTERIA RESISTANCE TOAMOXYCILLIN & AMPICILLIN BUT SENSITIVE TO COMBINATION OF AMOXYCILLIN +CLAVULANIC ACIDPRODUCING AUGMENTIN WHICH IS VERY EFFECTIVEAGAINST E.COLI,KLEBSIELA,STAPHYLOCOCCI.VERY USEFUL IN BITES WOUNDS (ANIMAL OR

HUMAN).

BACTEROIDS:VERY SENSITIVE TO METRONIDAZOLE (FLAGYL),THIRD GENERATION CEPHALOSPORIN (CL-AFORAN).MEROPENEM,TAZOCIN.

IN INFECTION DUE TO COMBINED MICROORGANISM

IN COLORECTAL SURGERY,SEVER ORAL CAVITY INFECT-ION,GYNAECOLOGICAL SURGERY.THE ORGANISMS RESPONSIBLE ARE E.COLI,PROTEUS,KLEBSIELA,AND BACTEROIDS SO WE GIVE:GENTAMYCIN+FLAGYL .OR CEFAFUROXIME+FLAGYL.OR MEROPENEM ALONE ,TAZOCIN ALONE OR COMB-INED WITH FLAGYL.QUINOLONES (CLINAFLOXACIN,SITAFLOXACIN).LINCOCIN.