Blok 17 - Infeksi

dr.
Ronald V Munthe SpOT

Infection
Is a condition in which pathogenic

organism multiply and spread
within the body tissues
Classical sign : Kalor, Rubor, Dolor, Tumor, LOF

Stab wound, operation, Blood stream (hematogen)
open fracture Nose, mouth, bowel, GU tract
Directly Indirectly
type of invader
the site of infection
the host response
Acute Pyogenic Sub-acute Phase Chronic Granulomatous

Infection Reaction
Pus Granuloma
(defunct leucocytes, dead bacteria (lymphocyte, macrophage
tissue debris) giant cell)
Host susceptibility
Local Factor: Systemic factor
Trauma Malnutrition
Poor circulation Diabetes
Sensiblity Imunitas
Foreign body (+) Debility
Chronic bone or joint
disease
Acute Haematogenous Osteomyelitis
Common in children
Adults with special condition

diabetes, immunocompromised, malnutrition, drug user
Post-traumatic event
haematomes, fluid collection
Gram + Gram -
Staphylococcus Aureus Haemophylus Influenza
Streptococcus Pyogenes E. Coli
Streptococcus Pneumonia Pseudomonas Aerogenosa
Proteus Miriabilis
Bacteroides Fragilis
Characteristic Pattern
Inflammation
Suppuration
Necrosis
New Bone Formation
Resolution or
Intractable chronicity
Inflammation
Vascular congestion
exudation of fluid leucocyte infiltration
intra-osseus pressure
PAIN
Suppuration
Suppuration
Necrosis
intra-osseus pressure Periosteal Stripping

vascular stasis, thrombosis due to pus
Compromise blood supply

+
Bacterial toxins
Bone death sequestra

New Bone Formation
Stripped periosteum Deep layer new bone formation
Involucrum
Enclose the infected bone

& sequestra
Resolution or
Intractable Chronicity
Healing Antibiotics & Intraosseus decompression
Remodelling Normal bone contour

Clinical Features
Look Feel
Swelling Pain
Hyperaemia Febris
Pus discharge Fluctuation
Lymphadenopati Tachicardia
History of infection Tenderness
Move
Refuse to use affected limb
Not appear in early antibiotocs treatment

Diagnostic Imaging
Diagnostic Imaging
X-Rays
No abnormalities
Displacement
Combination
fat plane Extra cortical outline Patchy rarefication
Osteoporotic
Haematoma Periosteal new bone metaphysis
Inc. dense
swelling
1-2 days 10-14 days >21 days

Diagnostic Imaging
Diagnostic Imaging
USG Detect fluid collection
Radioscintigraphy Increased activity in both phase

99mTc-HDP
67Ga-citrate or 111 ln Sensitive but not spesific
Sensitive
MRI & CT Differentiate
Soft tissue infection & Osteomyelitis
Diagnostic Imaging
Diagnostic Imaging
The most certain way to confirm
the clinical diagnosis
is to aspirate pus from
the metaphyseal subperiosteal
abscess or the adjacent joint
Pus -
Bacteroidal examination
&
Antibiotics sensitivity
Laboratory
White cell count
C-Reactive Protein
ESR
Blood Culture +
Differential Diagnose
Cellulitis
Streptococcal Necrotizing Myositis
Acute Suppurative Arthritis
Acute Rheumatism
Sickle Cell Crisis
Gauchers Disease
Treatment
If osteomyelitis is suspected on clinical grounds,

blood and fluid samples should be taken and
then
treatment started immediately without waiting
for final confirmation of the diagnosis
Treatment Principles
Provide analgesia
Rest affected part
Identify organism and give antibiotic
Pus evacuation and necrotic tissue
Stabilize bone if it has fractured
Treatment
Supportive Treatment
Splintage
Antibiotic Therapy
Surgical Drainage
Treatment
Analgesic
Septicaemia & Fever Dehydration

Treatment
Antibiotic Therapy
the prompt administration

of antibiotics is so vital, that treatment
should not await the result
Take the best guest
patient's age, general state of resistance, renal function,

degree of toxaemia and previous history of allergy
Must be taken into account
Treatment
Antibiotic Therapy
I.V (1-2 weeks)

Adults
flucloxacillin & fusidic acid
Staphylococcal
Oral (3-6 weeks)
I.V Cephalosporin
Children (cefuroxime / cefotaxime)
Haemophylus
Oral Amoxyclav
Treatment
Surgical Drainage
if the clinical features do not

improve within 36 hours of starting treatment, or even
before that if there are signs of deep pus (swelling,
oedema, fluctuation), and most certainly if pus is aspirated,
the abscess should be drained by open operation
under general anaesthesia
if there is an extensive intramedullary abscess

drainage can be better achieved
by cutting a small window in the cortex
Complication
Metastatic Infection
Suppurative Arthritis
Altered Bone Growth
Chronic Osteomyelitis
Sub-Acute Haematogenous
Osteomyelitis
presumably due to
the organism being less virulent or
the patient more resistant (or both)
Sub-Acute Haematogenous Osteomyelitis
Typically there is a well-defined cavity in cancellous

bone, containing glairy seropurulent fluid
The cavity is lined by granulation tissue containing a

mixture of acute and chronic inflammatory cells
The surrounding bone trabeculae are often thickened

Clinical Features
Pain near one of the larger joints
for several weeks or even months
May have a limp and often there is

slight swelling, muscle wasting and local tenderness.
The temperature is usually normal and there is little to

suggest an infection.
The white cell count may be normal

but the ESR is often raised
Imaging
The typical radiographic lesion is a circumscribed,
round or oval cavity 1-2 cm in diameter,
most often it is seen
in the tibial or femoral metaphysis
Sometimes the 'cavity' is surrounded by a

halo of sclerosis, the classic Brodie's abscess
The radioisotope scan shows

markedly increased activity
The clinical and x-ray appearances

may resemble those
of an osteoid osteoma
Biopsy is a gold standard for diagnosis
If fluid is encountered,
it should be sent for bacteriological culture
Treatment
Conservative
immobilization and antibiotics

(flucloxacillin and fusidic acid) for 6 weeks
usually result in healing
Curettage is also indicated

if the x-ray shows that there is no healing
after conservative treatment
dreaded sequel to
unresolved acute haematogenous osteomyelitis
The usual organisms

(and with time there is always a mixed infection)
are Staph, aureus. E. coli. S. pyogenes.
Proteus and Pseudomonas
Sequestra
Pus
Vascular Tissue
Sclerotic Area
Sequestra & Foreign implant act as substrate for bacterial adhesion

Clinical Features
The patient presents because

pain, pyrexia, redness and
tenderness have recurred
(a 'flare')
or with a discharging sinus
Laboratory
During acute flares

the ESR and blood white cell count
may be increased, these non-specific signs are helpful
in assessing the progress of bone infection
but they are not diagnostic
Antistaphylococcal antibody titres may be elevated

a valuable sign in the diagnosis of hidden infections and
in tracking progress to recovery
Treatment
Stop the spreading
Antibiotics
Seldom eradicate by antibiotics alone
Control the acute flares
Choice depends on bacteriological studies

Capable of penetrating sclerotic bone
Non-toxic with long-term use
Treatment
Local Treatment
Sinus dressing
Colostomy paste
Incission & Drainage for acute abcess
Treatment
Significant symptoms Operation

Clear evidence of a sequestrum or
dead bone
All infected soft tissue and Excised

all dead or devitalized bone
Dead material can be identified by the preoperative injection

of sulphan blue which stains all living tissues
green, leaving dead material unstained
Treatment
Treatment
Papineau Technique
Fill completely the dead space left after excision of necrotic tissue with
living or potentially living material
Cancellous bone graft

(autogenous)
Antobiotic Muscle-flap transfer
Fibrin sealant
Split skin graft
Post Traumatic Osteomyelitis
Common in adults
The combination of tissue injury, vascular damage,

oedema, haematoma, dead fragments and
an open pathway to the atmosphere
Staph. Aureus
Feverish and develops pain and
swelling over the fracture site, the wound is
inflamed
and there may be a seropurulent discharge
Treatment : debridement, antibiotics, delayed

wound closure
Post Operative Osteomyelitis
The true incidence is probably around 5%
considerably greater in the elderly, the obese, those with diabetes or other chronic diseases, patients with
sickle-cell disease, Gaucher's disease or
leukaemia, patients on corticosteroid or immunosuppressive
therapy, and patients who have had
multiple previous operations at the same site
mixture of pathogenic bacteria

(Staph, aureus, Proteus, E. coli, Pseudomonas)
Organisms may be introduced directly into the

wound from the atmosphere, the instruments,
The patient or the surgeon
(1) soft-tissue damage

(2) haematoma formation
(3) Bone death
'the race for the surface'

(Gristina, 1988)
foreign implant is both a predisposing

factor and an important element in its persistence.
Bacteria as well as human tissue cells have an
affinity for molecules on the surface of the implant.
Both compete for occupancy of the same surface -
the tissue cells by adaptation and integration, the
bacteria by adhesion and colonization
Early
Intermediate Post Operative
Late Osteomyelitis
'Prevention is better than cure
(1) avoiding operations on immune-depressed patients

(2) eliminating any focus of infection before operating
(3) insisting on optimal operative sterility
(4) giving prophylactic antibiotics
(5) handling tissues gently
(6) using high-quality implant materials
(7) ensuring close fit and secure fixation of the implant
(8) preventing or counteracting later intercurrent infection
Antobiotics Treatment
Septic arthritis
Septic arthritis; terjadi akibat osteomielitis
pada tulang metaphysis yang terletak intra
capsular
Septic arthritis juga terjadi akibat inokulasi
bakteri langsung ke dalam sendi ,
misalnya trauma tembus ke dalam sendi
atau infeksi menembus jaringan lempeng
epiphysis
Septic arthritis
Septic arthritis
Infeksi bakteri yang menyerang jaringan
synovium dan ruang / kapsul sendi yang
mengakibatkan berkumpulnya reaksi sel-
sel PMN dan ilepaskannya enzym
proteolitik
Infeksi sendi
Septic arthritis
Septic bursitis
Infeksi pada pasien pasca total Hip / knee
replacement
Faktor predisposisi
Peny sendi kronis Riwayat aspirasi sendi
Trauma / injeksi
Rheumatiod arthritis Gangguan /
Diabetes melitus insufisiensi vascular
Terapi steroid Riwayat infeksi sendi
sebelumnya
Gagal ginjal
Keganasan
Drug abuse
Sendi predileksi
Lutut 53% Predileksi pada anak :
Hip 20%
Bahu 11 % Paling sering sendi
Siku 17% lutut 39 %
Wrist 9 % Panggul 32 %
Ankle 8 %
Kuman penyebab
Staphylococcus aureus
Strepticoccus sp
Gram negatif
Pnoumococcus
Kuman penyebab
Anak di bawah 2 th :
Haemophylus influensa
Tes diagnostik
Lab :
Leukosit
LED > 20
Kultur darah
(+)35 %
Pemeriksaan radiologi
Soft tissue : bengkak
Effusi cairan sensi
CT scan
Bone scan Tc 99
Prinsip terapi
Menghambat multiplikasi kuman dg
antibiotik
Drainage abses superiosteal ( bila sudah
terbentuk )
Penatalaksanaan
Kultur resistensi
Antibiotik intra vena : 2- 4 minggu
Operasi drainage

Blok 17 - Infeksi

Загружено:

Сведения о документе

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Blok 17 - Infeksi

Загружено:

Авторское право:

Доступные форматы

dr.

Ronald V Munthe SpOT

Is a condition in which pathogenic

Classical sign : Kalor, Rubor, Dolor, Tumor, LOF

Acute Pyogenic Sub-acute Phase Chronic Granulomatous

Adults with special condition

Staphylococcus Aureus Haemophylus Influenza

Streptococcus Pyogenes E. Coli

Streptococcus Pneumonia Pseudomonas Aerogenosa

New Bone Formation

intra-osseus pressure Periosteal Stripping

Compromise blood supply

Bone death sequestra

New Bone Formation

Stripped periosteum Deep layer new bone formation

Enclose the infected bone

Healing Antibiotics & Intraosseus decompression

Remodelling Normal bone contour

Not appear in early antibiotocs treatment

1-2 days 10-14 days >21 days

USG Detect fluid collection

Radioscintigraphy Increased activity in both phase

White cell count

Streptococcal Necrotizing Myositis

Acute Suppurative Arthritis

Sickle Cell Crisis

If osteomyelitis is suspected on clinical grounds,

Septicaemia & Fever Dehydration

the prompt administration

Take the best guest

patient's age, general state of resistance, renal function,

I.V (1-2 weeks)

if the clinical features do not

if there is an extensive intramedullary abscess

Altered Bone Growth

Typically there is a well-defined cavity in cancellous

The cavity is lined by granulation tissue containing a

The surrounding bone trabeculae are often thickened

May have a limp and often there is

The temperature is usually normal and there is little to

The white cell count may be normal

Sometimes the 'cavity' is surrounded by a

The radioisotope scan shows

The clinical and x-ray appearances

Biopsy is a gold standard for diagnosis

immobilization and antibiotics

Curettage is also indicated

The usual organisms

Sequestra & Foreign implant act as substrate for bacterial adhesion

The patient presents because

During acute flares

Antistaphylococcal antibody titres may be elevated

Choice depends on bacteriological studies

Significant symptoms Operation

All infected soft tissue and Excised

Dead material can be identified by the preoperative injection

Cancellous bone graft

Antobiotic Muscle-flap transfer

The combination of tissue injury, vascular damage,

Treatment : debridement, antibiotics, delayed

The true incidence is probably around 5%

mixture of pathogenic bacteria

Organisms may be introduced directly into the

(1) soft-tissue damage