•SURGICALLY

•IMPORTANT
INFECTIONS

Dr. Hiwa Omer Ahmed

Assistant Professor in General Surgery
Iceberg
 Microbial Pathogenicity
opportunistic infection
•

The ability of a microbe to cause infection

is a balance between host
defenses and microbial pathogenicity.
Some microbes that have virtually no
ability to cause infection in the normal host
can cause lethal infection in an
individual with compromised host
defenses.
• Many bacteria .
Klebsiella
pneumoniae,
Streptococcus pyogenes,
Staphylococcus aureus,
Salmonella typhi) and
•
 fungi(Histoplasma capsulatum, Candida
albicans,Cryptococcus neoformans

• have thick capsules that make them resistant to

phagocytosis
• Other microbes (Mycobacterium tuberculosis,
Aspergillus flavus, and Toxoplasma gondii)
resist intracellular killing after they have been
phagocytosed when lysosomes that contain
enzymes that digest microbes do not fuse
with the phagosome. Other microbes
successfully resist digestion by lysosomal
enzymes.
 Exotoxins
•
Some bacteria can elaborate toxins, many of
which are enzymes that injure or kill cells or
promote spread within tissues. Exotoxins play an
importantrole in the pathogenicity of
Clostridium species, Staph. aureus, and
Strep.pyogenes.
• Other bacteria (Clostridium tetani,
Clostridium botulinum)
elaborate neurotoxins that alter normal neural
transmission.
 Endotoxins
•
Endotoxins are lipopolysaccharide-protein
complexes that are normal
constituents of the cell wall of gram-negative
bacteria. These molecules activate many
biological pathways, including the complement
and coagulation systems, and cause release of
cytokines and other biologic mediators from
macrophages, release of hormones, and
alteration in metabolism.
 Necrotizing Soft Tissue
Infections; necrotizing fasciitis
•
Necrotizing Soft Tissue Infections
Soft tissue infections that cause necrosis are
more serious because of their propensity for
extensive tissue destruction and high mortality
rates. The nomenclature for necrotizing soft
tissue infections is confusing. Terms
such as necrotizing fasciitis, streptococcal
gangrene, gas gangrene,
bacterial synergistic gangrene, clostridial
myonecrosis, and Fournier's
gangrene are commonly used.
 Necrotizing Soft Tissue
Infections; necrotizing fasciitis
• Attempts to differentiate these infections on
the basis of predisposing conditions, presence of
pain, toxic condition,
fever, presence of crepitus, appearance of the
skin and subcutaneous
tissues, and presence of bullae are of little help
in diagnosis or initial
treatment. Bacteria seldom respect anatomic
barriers, and hence necrotizing fasciitis is rarely
limited to fascia and myonecrosis is frequently
not limited to muscle.
Necrotizing Fascitis; syn gan
Necrotizing Fascitis; syn gan
 Infective Gangrene
•
The term gas gangrene has become
synonymous with clostridial infection. But
the presence of gas in tissue simply means
that anaerobic bacterial metabolism has
produced insoluble gases such as hydrogen,
nitrogen, and methane. Both facultative and
obligate anaerobes are capable of such
metabolic activity. Aerobic bacteria can also
produce gas. Gas in tissues is much more
likely to be caused by bacteria other than
Infective Gangrene
C Perfringins
 Infective Gangrene
•
Clostridium species. Strep. pyogenes can also
causeextensive tissue necrosis. Halophilic
marine Vibrio species can cause rapidly
progressive necrotizing soft tissue infections,
especially in individuals with liver disease. Fungi
too can cause necrotizing cutaneous and
subcutaneous infection, but these infections
progress much more slowly than do bacterial
infections.
Infective Gangrene; gas gang.
 Tetanus

•
Tetanus is caused by
Clostridium tetani, a large gram-positive
spore-forming bacillus.
 Tetanus

•
C. tetani is usually acquired by
implantation of the organisms into tissues
by means of breaks in the mucosal or skin
barriers.
•
said that tetanus occurs in dirty, necrotic, and
neglected wounds, the majority of cases in the
United States appear after punctures,
lacerations, and abrasions. Tetanus can appear
after surgical wounds, injections, and inpatients
that have no apparent injury at all. Organisms
proliferate at the site of inoculation and have
virtually no capacity for causing an invasive
infection.
 Tetanus toxins,
• Clinical tetanus is as much an intoxication as an
infection.C. tetani elaborates two toxins,
• 1. tetanospasmin
elaborates two toxins, tetanospasmin
andtetanolysin.Tetanospasmin acts on the
anterior horn cells of the spinal cord and on the
brain stem. It blocks inhibitor synapses at these
sites, leading to muscle spasms and
hyperreflexia.
 Tetanus
• 2. tetanolysin
. Tetanolysin is cardiotoxic and causes
hemolysis, but itis not thought to be of
major clinical importance
 stages
• Period of onset; 1st symp.>1st reflex spasm
• Initial; stiffness ,decreased breathing,
Sardonic smiles
• Tonic m spasm ; sparing limbs
( strychnine)
• All muscles+ severe pain< spon or trival
stimuli
• Last severe> cyanosis ,apnea
 Tetanus
• The median incubation period is 7 to 8
days
• Tetanus usually appears in generalized
form but occasionally appears as localized
tetanus with increased muscle tone and
spasms confined to muscles near the
wound and without systemic signs
 Tetanus
• symptoms of restlessness and headache.
• symptoms are muscle spasms with vague
discomfort in the neck, lumbar
region, and jaws. Spasm of the
pharyngeal muscles makes swallowing
difficult. until the spasms become
generalized
•
Orthotonos, opisthotonos, and emprosthotonos
can develop. Generalized toxic convulsions are
frequent, exhausting, and unpredictable. Any
slight external stimulus (a breeze, sudden
movement, noise, or light) and internal
stimuli (cough, swallow, distended bladder) may
trigger generalized convulsions. These
convulsions may involve the laryngeal and
respiratorymuscles and result in fatal acute
asphyxia
 DDx
• Follicular tonsillitis
• Back strain
• Acute abdomen
• HYS
prevension
Tetanus opisthotonos
Tetanus opisthotonos
Tetanus neonatorum
 Anthrax
• Anthrax is infection with the gram-positive
bacterium Bacillus anthracis that typically
involves the skin, lungs, or digestive tract
Anthrax bacillus
Anthrax bacillus
Anthrax bacillus
 spread
• Anthrax is a potentially fatal disease that
usually spreads to people from animals,
especially cows, goats, and sheep
 Bacteria spore
• Dormant bacteria (spores) can live in soil
and in animal products (such as wool) for
decades and are not easily killed by cold
or heat. Even minimal contact is likely to
result in infection. Although infection in
people usually occurs through the skin, it
can also result from inhaling spores or
from eating contaminated, poorly cooked
meat. Infection cannot spread from person
to person.
• Because anthrax is highly lethal when inhaled,
it has been considered and used by some
countries and terrorists as an agent of
biological warfare (Anthrax bacilli produce
several toxins, which are responsible for many
of the symptoms.
 features

• Anthrax skin infection begins as a painless, red-

brown bump that appears 1 to 5 days after
infection. The bump forms a blister, which
hardens and eventually breaks open to form a
black scab (eschar)
features
features
Anthrax
• Lymph nodes in the affected area may
swell, and the person may feel ill—
sometimes experiencing muscle aches,
headache, fever, nausea, and vomiting.
One in five untreated people dies.
Bubo ,Plague
Pulmonary anthrax
 Pulmonary anthrax
• Pulmonary anthrax (woolsorter's disease) results
from inhaling the spores of the anthrax
bacterium. The spores multiply in the lymph
nodes near the lungs. Toxins produced by the
bacteria cause the lymph nodes to swell, break
down, and bleed, spreading the infection to
nearby structures in the chest. Infected fluid
builds up in the lungs and in the space between
the lungs and the chest wall. Symptoms develop
in two stages. For the first 2 to 3 days, the
symptoms are vague and similar to those of
influenza, with mild aches, fever, and dry cough
• The person then suddenly develops
severe difficulty breathing, high fever, and
sweating, rapidly followed by shock and
coma. This second stage is probably the
result of a massive release of toxins.
Infection of the brain and meninges
(meningoencephalitis) may also occur.
Many people die 24 to 36 hours after
severe symptoms start, even with early
treatment
 Digestive anthrax
• Anthrax of the digestive tract
(gastrointestinal anthrax) is rare. When a
person eats contaminated meat, the
bacteria grow in the mouth, throat, or
intestines and release toxins that cause
extensive bleeding and tissue death. Sore
throat, neck swelling, abdominal pain,
vomiting, and bloody diarrhea also
develop. At least half of the untreated
people die
csf
 prevention
• People at high risk of contracting anthrax—such
as veterinarians, laboratory technicians, and
employees of textile mills that process animal
hair—can be vaccinated. Because of anthrax's
potential as a biological weapon, most members
of the armed forces are also vaccinated. Despite
widely publicized anxiety, well over 1.25 million
people have received anthrax vaccine without
serious adverse reactions
prevention
 Rx
• People exposed to anthrax may be given
preventive treatment using either oral
ciprofloxacin , or doxycycline

• if the bacteria's susceptibility to penicillin is

unknown. If susceptibility to penicillin is
documented, children should be given
preventive treatment with oral amoxicillin
• Anthrax infection is treated with a
combination of antibiotics, including
intravenous ciprofloxacin , or doxycycline ,
plus clindamycin , rifampin, or penicillin.

• Corticosteroids may also be used to

reduce any swelling in the throat. The
longer treatment is delayed, the greater
the risk of death
 Syphilis
• Syphilis (pronounced SIF-uh-lus) is a
sexually transmitted disease caused by bacteria.
The highly infectious disease may also be
passed, but much less often, through blood
transfusions or from mother to fetus in the
womb. Without treatment, syphilis can cause
irreversible damage to the brain, nerves, and
body tissues.
• The symptoms of syphilis can mimic many
diseases. Sir William Osler stated, "The
physician who knows syphilis knows medicine."
 Syphilis
• Syphilis is an infectious, often sexually
transmitted, disease caused by the bacteria
Treponema pallidum. The bacteria penetrate
chafed skin or the mucous membranes.
• Transmission most often occurs when one
person comes into contact with lesions on an
infected person through sexual activity.
• Men are more vulnerable to contracting syphilis
than women.
• The active disease is found most often
among men and women aged 15-39 years.
syphilis
 Primary phase
• Syphilis may progress through 3 distinct stages.
Sometimes not all 3 may be evident.
• Primary phase: The primary phase usually starts with a
sore at the site of infection. The sore or lesion is called a
chancre (pronounced shanker). This sore usually
appears as a craterlike lesion on the male or female
genitals, although any part of the body is at risk. Anyone
who touches an infected sore can transmit the infection.
This initial lesion develops 3-4 weeks after infection and
heals spontaneously after 1 week. Though the sore goes
away, the disease does not. It progresses into the
secondary phase.
1 st
stage Syphilis Chancre
2 nd
stage Syphilis ulcer
 Secondary phase
• Secondary phase: The secondary phase
may develop 4-10 weeks after the
chancre. This phase has many symptoms,
which is why syphilis is called the great
pretender. It may look like a number of
other illnesses. This phase of syphilis can
go away without treatment, but the
disease then enters the third phase.
These are the most frequently reported
symptoms of the secondary phase:
 Secondary phase
– Fever
– Joint pain
– Muscle aches
– Sore throat
– Flulike symptoms
– Whole-body rash (usually involving the palms and
soles)
– Headache
– Decreased appetite
– Patchy hair loss
– Swollen lymph nodes
3 rd
stage Syphilis
 Latent (dormant) phase
• Latent (dormant) phase: The early latent
phase (first 1-2 years) is characterized by
occasional relapses back to symptoms of
the secondary phase of syphilis. More
than 2 years after the start of the latent
phase, you may have no symptoms and
are generally not infectious. However, you
can still transmit the infection from mother
to fetus or through blood transfusions
 tertiary syphilis
– About a third of people with latent syphilis will
progress after many years (or decades) into
tertiary syphilis. During this phase, the heart,
brain, skin, and bones are at risk. Luckily, with
the advent of penicillin, this phase is very
rarely seen today.
 Congenital syphilis
• Congenital syphilis occurs after a fetus is
infected in the womb. This form of syphilis
causes teeth abnormalities, bone
problems, liver/spleen/kidney
enlargement, brain infection, failure to
thrive/poor growth, swollen lymph nodes,
yellow skin (jaundice), low blood counts,
and skin rashes
Syphilis; congenital
 Syphilis Dx
• Secondary syphilis Blood testing is the
cornerstone of diagnosis during the
secondary phase. The doctor will usually
order one of the following tests. All three
help diagnose a syphilis infection.
• RPR (rapid plasma reagin)
• VDRL (venereal disease research laboratory)
• FTA-ABS (fluorescent treponemal antibody
absorption) or MHA-TP (microhemagglutination
assay for T pallidum)
 Syphilis Dx
• During the tertiary phase, may need
sample of spinal fluid to check for infection
and to measure the success of treatment.
 Syphilis Rx
• . During the primary, secondary, and early latent
phases of syphilis, a single injection of penicillin
cures the disease. People who are allergic to
penicillin (and not pregnant) may be given oral
antibiotics (such as doxycycline, tetracycline, or
erythromycin) for 2 weeks.
• People who are diagnosed to be in the late
latent stage of syphilis (and are not sure how
long they have been in this stage) and those
with tertiary syphilis will require 3 injections,
each 1 week apart. Oral antibiotics (most likely,
doxycycline or tetracycline) are usually given to
people in this stage who are allergic to penicillin.
• If syphilis has advanced to neurosyphilis (or
brain involvement), treatment with IV penicillin
every 4 hours for 10-14 days may be required.
An alternative is penicillin injections (once per
day) with oral probenecid (4 times a day) for 10-
14 days.
• A pregnant woman with syphilis must have
penicillin, even if she is allergic to it. She must
tell her doctor of this allergy to allow for
desensitization procedures.
 Jarisch-Herxheimer reaction
• After treatment with penicillin, a Jarisch-
Herxheimer reaction may occur 2-12
hours after treatment starts. This reaction
is the result of the dying bacteria and may
cause previous symptoms to
transiently worsen. Alarming as it may be,
this reaction usually ends within 24 hours.
Bed rest, pain relievers (such as aspirin,
acetaminophen, or ibuprofen), and liquids
can help
HIV > AIDS
 human immunodeficiency virus
• HIV (human immunodeficiency virus) infection
has now spread to every country in the world
and has infected more than 40 million people
worldwide as of the end of 2003. More than 1.1
million people in the United States have been
infected with HIV. The scourge of HIV has been
particularly devastating in Sub-Saharan Africa.
The proportion of adult women among those
infected with HIV is increasing.
Global distribution
 human
immunodeficien
cy virus

•
HIV: A lentivirus of a subgroup of retroviruses,
HIV causes AIDS. The virus kills or damages
cells of the body’s immune system. HIV
progressively destroys the body’s ability to fight
infections and certain cancers. People
diagnosed with AIDS may develop life-
threatening diseases from viruses or bacteria
that rarely make healthy people sick. These
infections are called opportunistic infections.
• An electronic micrograph of HIV particles
showing central core and an outer
envelope.
human immunodeficiency virus
 human immunodeficiency virus
•
AIDS: Acquired immunodeficiency
syndrome was first recognized in 1981 in
New York City. The epidemic is growing
most rapidly among minority populations.
The virus was identified in 1983. A
diagnostic blood test was developed in
1985.
 HIV. AIDS
• Research on HIV infection includes the
development and testing of HIV vaccines and
new therapies for the disease and its associated
conditions. Currently, 28 HIV vaccines are being
tested on humans, and many drugs for HIV- or
AIDS-associated infections are either being
developed or tested. Researchers are also
investigating how HIV damages the immune
system and are trying to trace how the disease
progresses in different people.
 HIV. AIDS
• Most commonly, HIV infection is spread by
having sex with an infected partner. The
virus can enter the body through the lining
of the vagina, vulva, penis, rectum, or
mouth during sex. Although initially AIDS
cases occurred primarily in homosexual
males in the United States, more recently
the majority of new cases are in the
heterosexual population
 HIV. AIDS
• HIV also spreads through contact with infected blood
through a transfusion of contaminated blood or blood
components.
• HIV frequently spreads among injection drug users who
share needles or syringes that are contaminated with
blood from an infected person.
• Women can transmit HIV to their babies during
pregnancy or birth.
• The virus does not spread through casual contact such
as sharing of food, utensils, towels and bedding,
swimming pools, telephones, or toilet seats. The virus is
also unlikely to be spread by contact with saliva.
 HIV. AIDS
• People who already have a
sexually transmitted disease, such as
syphilis, genital herpes, chlamydial
infection, gonorrhea, or bacterial
vaginosis, are more likely to acquire HIV
infection during sex with an infected
partner
 features
• Many people do not develop symptoms
after getting infected with HIV. Some
people have a flu-like illness within several
days to weeks after exposure to the virus.
They complain of fever, headache,
tiredness, and enlarged lymph glands in
the neck. These symptoms usually
disappear on their own within a few weeks
 features
• Following initial infection, you may have no
symptoms. The progression of disease varies
widely among individuals. This state may last
from a few months to more than 10 years.
– During this period, the virus continues to multiply
actively and infects and kills the cells of the immune
system. The immune system allows us to fight against
the bacteria, viruses, and other infectious causes.
– The virus destroys the cells that are the primary
infection fighters, called CD4+ or T4 cells.
 features
• Once the immune system weakens, a person
infected with HIV can develop the following
symptoms:
– Lack of energy
– Weight loss
– Frequent fevers and sweats
– Persistent or frequent yeast infections
– Persistent skin rashes or flaky skin
– Short-term memory loss
– Mouth, genital, or anal sores from herpes infections.
 Aids stage
• AIDS is the most advanced stage of HIV infection. The
definition of AIDS includes all HIV-infected people who
have fewer than 200 CD4+ cells per microliter of blood.
The definition also includes 26 conditions that are
common in advanced HIV disease but that rarely occur
in healthy people. Most of these conditions are infections
caused by bacteria, viruses, fungi, parasites, and other
organisms. Opportunistic infections are common in
people with AIDS. Nearly every organ system is affected.
Some of the common symptoms include the following:
– Cough and shortness of breath
– Seizures and lack of coordination
 Aids stage
– Difficult or painful swallowing
– Mental symptoms such as confusion and
forgetfulness
– Severe and persistent diarrhea
– Fever
– Vision loss
– Nausea, abdominal cramps, and vomiting
– Weight loss and extreme fatigue
– Severe headaches with neck stiffness
– Coma
 complications
• People with AIDS are prone to develop
various cancers such as Kaposi sarcoma,
cervical cancer, and cancers of the
immune system known as lymphomas.
Kaposi sarcoma causes round, brown,
reddish or purple spots that develop in the
skin or in the mouth. After the diagnosis of
AIDS is made, the average survival time
has been estimated to be 2-3 years.
Kaposi sarcoma
Kaposi sarcoma
complications
complications
 Dx
• Two different types of antibody tests, enzyme-
linked immunoassay (ELISA) and Western blot,
are available. The screening test is the ELISA
test, and Western blot is the confirmatory test.
Both of these tests can be negative for up to 3
months after the exposure. In this situation, if the
suspicion for HIV infection remains high,
another, more accurate test can be performed.
This test directly looks for the actual HIV
particles in the blood.
Dx
HIV infection
Conversion; RNA > DNA
Splitting
Transcription
 Medications|
• Reverse transcriptase inhibitors: They
interrupt the virus from making copies of
itself. These drugs are AZT (zidovudine
[Retrovir]), ddC (zalcitabine [Hivid],
dideoxyinosine), d4T (stavudine [Zerit]),
and 3TC (lamivudine [Epivir]). These
drugs may slow the spread of HIV in the
body and delay the onset of opportunistic
infections
 Rx
•
Nonnucleoside reverse transcriptase
inhibitors (NNRTIS): These medications
are used in combination with other drugs
to help keep the virus from multiplying.
Examples of NNRTIS are delavirdine
(Rescriptor) and nevirapine (Viramune).
 Rx
•
Protease inhibitors: These medications
interrupt virus replication at a later step in
its life cycle. These include ritonavir
(Norvir), a lopinavir and ritonavir
combination (Kaletra), saquinavir
(Invirase), indinavir sulphate (Crixivan),
amprenavir (Agenerase), and nelfinavir
(Viracept). Using both classes of drugs
reduces the chances of developing
resistance in the virus.
 Rx
•
Fusion inhibitors: This is the newest class
of anti-HIV drugs. The first drug of this
class (enfuvirtide [Fuzeon]) has recently
been approved in the United States.
Fusion inhibitors block HIV from entering
the human immune cell.
 Side effects
•
The antiretroviral viral drugs do not cure people
of HIV infection or AIDS. They stop viral
replication and delay the development of AIDS.
However, they also have side effects that can be
severe.
•
1. They include decrease of red or white blood
cells, inflammation of the pancreas, and painful
nerve damage.
•
2. Other complications are enlarged liver and
fatty liver, which may result in liver failure and
death.
•
The common side effects from protease
inhibitors include nausea, diarrhea, and
other gastrointestinal symptoms. These
drugs can interact with other drugs and
result in serious side effects.
 HIV & health staffs
•
Many prospective studies have examined the
actual risk of HCWs becoming infected with HIV
after sustaining a percutaneous exposure to
blood or blood-containing body fluids from
patients with HIV infection. Of 1,948HCWs in 12
reports who sustained a total of 1,051 mucous
membrane
exposures to blood or blood-containing body
fluids from HIV-infected
patients, six (0.29 percent per exposure)
seroconverted.
 HIV
• Risk of HIV
infection is associated with deep injury,
visible blood on the device,
procedure involving a needle placed
directly in a vein or artery, terminal
illness in the source patient, and no
postexposure use of zidovudine
(AZT).
 HIV
• Surgeons are frequently exposed to
patient's blood and other body fluids.
Most exposures are to the skin, and their
numbers can be minimized by
wearing two pairs of gloves and face
shields. Survey studies show that
percutaneous injuries occur in 5.6 percent
of operations, and 86 percent of
surgeons report at least one percutaneous
injury per year.
 effects
• Attack gp120 on CD4 in
• T lymphocyte
• Macrophage
• Dendrites
• Renal cells
• Epithelial cells
 On infection
• 1. CD 4 depleted
• 2. dendrites destroyed
• 3. thymus damaged
• 4. immune system dys-regulated >
• auto antibodies
• persistent complement activation
 Features are of
• Disorders of antibody production
• Delayed hypersensitivity
• Macrophage dysfunction
• Depletion of GIT and other IgA
 features
• Virus reaches blood :>
brief seroconversion;
flue like
LNs
Remains symptom free, but CD4
lymphocyte depleted
In 2 years 25-35 % > AIDS mortality 100%
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