Peritonitis

Micro-organism enter the sterile abdominal cavity and cause peritonitis if this infection goes untreated patient survives abscesses

INTRAABDOMINAL INFECTIONS 

The intraperitoneal infection, usually due to normal anatomic barrier is broken. This disorder can occur when the appendix, diverticulum, wound or ulcer ruptures, when the intestinal wall is impaired ischemia, tumor or infection (for example, in inflammatory bowel disease ), or adjacent to inflammatory processes, such as pancreatitis or inflammatory pelvic disease in which the enzyme (in the previous case), or bodies (in this case) can leak into the abdominal cavity.


Regardless incitement case, when the inflammation develops and bodies are often contained within the intestines or other body normally sterile peritoneal space, a predictable series of events takes place. intra-abdominal infections occur in two stages: peritonitis and if the patient survives this stage, and Treat an abscess formation. types of micro-organism every phase of infection are responsible for the pathogenesis of the disease.

Most intra-abdominal infections arise from a source in the gastrointestinal tract. They are usually caused by enteric aerobic and anaerobic. The management usually involves an invasive procedure to control the source of infection and antimicrobial therapy against pathogenic microorganisms. In a small number of highly selected patients, these infections can be treated without due process of final source code control.


Antimicrobial therapy is tailored to each patient, with narrow spectrum agents used to treat community infections intra-abdominal and wider spectrum of agents used for nosocomial infections. In general, these infections are associated with significant morbidity and mortality, especially among high-risk patients have impaired host defenses.

PERITONITIS 

Peritonitis Inflammation of the peritoneum, a thin line membrane covering the abdomen and internal organs. The inflammation caused by bacterial or fungal infections in this film. There are two different types of peritonitis. Primary peritonitis due to the spread of infection from blood and lymph to the peritoneum. This type of peritonitis rare - less than 1% of all peritonitis is a priority. The most common type of peritonitis-called secondary peritonitis, caused by infection of the peritoneum should be in the stomach or biliary tract. In both cases of peritonitis are very serious and can be fatal if not treated quickly....... read more

Primary ( Spontaneous )  bacterial peritonitis
Secondary peritonitis

Peritonitis in patients undergoing chronic ambulatory peritoneal dialysis

Abdominal infections

INTRAABDOMINAL INFECTIONS -INTRAPERITONEAL ABSCESSES 

Untreated peritonitis can form abscesses as an extension of the infection process and as an attempt by the host's defenses to contain the infection.Most of the abscesses can originate from colonic sources.Abscesses can occur anywhere in the abdomen and retroperitoneum. They mainly follow the operations, injuries or conditions involving abdominal infection and inflammation, especially when there is a perforation or peritonitis. Symptoms include malaise, fever and abdominal pain. The CT diagnosis. The treatment is drainage, either surgical or percutaneous. Antibiotics are auxiliary.

 

CAUSES 

 

Intra-abdominal abscesses can be  classified as

1. INTRAPERITONEAL 
2. RETRO-PERITONEAL OR VISCERAL 

INTRAABDOMINAL ABSCESSES. Many intra-abdominal abscess developing after perforation of a hollow organ or cancer of the colon. Others develop from the spread of infection or inflammation caused by conditions such as appendicitis, diverticulitis, Crohn's disease, pancreatitis, pelvic inflammatory disease or condition that causes generalized peritonitis. abdominal surgery, particularly those affecting the gastrointestinal tract or bile is another important risk factor: The peritoneum can become contaminated during or after surgery to events such as anastomotic leakage. lacerations and bruises abdominal injuries, especially liver, pancreas, spleen and intestine, abscesses can develop, whether treated or not functioning properly.

Transmitted  infecting organisms generally reflect the normal intestinal flora and a complex mixture of aerobic and anaerobic bacteria. The most common strains of aerobic gram-negative bacilli (e.g. Escherichia coli and Klebsiella) and anaerobic (Bacteroides fragilis in particular). undrained abscess can spread to adjacent structures, damage to the vessels surrounding the passage (due to bleeding or thrombosis), will rupture the peritoneum, or bowel or a skin fistula. sub-diaphragmatic abscess may extend to the thoracic cavity, resulting in empyema, lung abscess or pneumonia. abdominal abscess may track down the thigh or perirectal Fossa. splenic abscess is a rare cause of persistent bacterial endocarditis that persists despite appropriate antimicrobial therapy. 

 

CLINICAL PRESENTATION 

Wide range of presenting complaints , the patients may have general malaise and anorexia or weight loss, other people present in critically ill septic shock with acute abdomen. visceral abscesses do not develop gastrointestinal perforation after local disease (diverticulitis, etc), trauma or surgery, secondary peritonitis subsequently becomes walled by adhesions, inflammatory bowel loops or mesentery omentum abscess and other intra-abdominal abdominal viscera also can develop after primary peritonitis (spontaneous bacterial peritonitis). Sx: fever, pain, nausea, vomiting, anorexia. Physical examination: local pain, perhaps a palpable mass, post-operative evaluation of abscess confused by painkillers and pain in the incision, with more than half is within 10 days of the initial operation. Laboratry: elevated white blood cell count, the yield of direct aspiration of Gram-positive, anti-culture, positive blood cultures ~ 25% depending on the site.

DIAGNOSTIC INVESTIGATIONS 

 

CT SCAN  is more useful. Ultra Sound and Nuclear Magnetic Resonance  (MRI )from time to time ,is not used to guide the drainage. CT or ultrsound guided percutaneous or surgical drainage  to be considered in all cases to confirm the diagnosis, microbiological evaluation, and therapy. Indium gallium is rarely necessary for diagnosis with the advent of these new imaging modalities.

 

TREATMENT 

 

MEDICAL TREATMENT 

 

Antibiotic therapy requires parenteral administration of empirical antibiotics. Start treatment before the abscess drainage, and be careful when all signs of systemic sepsis is resolved. As the abscess fluid generally includes both aerobic and anaerobic organisms early empirical therapy directed against both microbes. This can be achieved by antibiotic treatment or combination therapy with broad spectrum, a management representative. Special treatment, then guided by the results of cultures, retrieved from a boil. Patients who are immunosuppressed, yeast fungi species can be an important pathogenic role, and amphotericin B therapy may be indicated.

 

DRAINAGE 

 

The drainage of pus is mandatory and is the first line of defense against infections gradually. Percutaneous catheter drainage guided by CT became the standard treatment for most intra-abdominal abscesses. It can be difficult to avoid laparotomy, requires anesthesia, eliminates the possibility of wound complications of open surgery, and may reduce the length of hospitalization. It also avoids the possibility of contamination of other areas in the peritoneal cavity. CT-guided drainage of the abscess cavity delimited and can provide secure access for percutaneous drainage. When performed by experienced hands, but also avoids the risk of injury to adjacent organs or blood vessels. 

 

After surgical drainage, clinical improvement should occur in 48-72 hours. The lack of improvement in this period, the second term of the CT review additional abscesses. surgical drainage should be compulsory, if the remaining liquid can be removed with irrigation catheter manipulation, merger or other investments.

 

SURGICAL INTERVENTION 

 

The surgical procedure can also be intended to persist with the content of abscesses, such as hematoma, infection, fungal infection or pancreatic abscesses. Surgical drainage is an option if the skin is dry or fails if the collections are not susceptible to drainage catheter. surgical approach can be either open or laparoscopic drainage (laparotomy) drainage. transperitoneal approach is safer to open a prudent use of preoperative antibiotics. Although contamination of otherwise non-infected sites is an important concern, this complication is particularly reduced if the organizations involved are sensitive to selected drugs. transabdominal examination of the abdomen and allows for full cleaning of fibrin. It also allows full bowel movement to identify and remove all synchronized with the abscesses, which occur in more than 23% of patients.

 

Improved clinical outcomes in three days after treatment indicates drainage. The lack of improvement may indicate inadequate drainage or any other source of infection. If left untreated, inevitably sepsis multiorgan failure. The transabdominal approach open to intra-abdominal abscess can be extremely difficult. Even Matt bowel and adhesions, and loss of anatomic integrity can pose serious problems. This is particularly true when the sensitive organs, like a loop of small intestine, observed intermittent wall abscess or cavity. Therefore, whenever possible, CT-guided drainage is a useful first step.

 

Food poisoning - Cholera - v.cholerae - rota virus infections

Babies in day care have an increased risk of infection by rotavirus ,giardia lamblia and compylobactor

INFECTIOUS  NON - INFLAMMATORY DIARRHEAS 

BACTERIAL FOOD POISONING 

 

Evidence of a common source outbreaks occur frequently. First Staphylococcus aureus enterotoxin produced in food left at room temperature (eg a picnic). The incubation period is 1-6 hours. Disease products within 12 hours, and consist of diarrhea, vomiting and stomach cramps usually without fever. Second Bacillus cereus . (A). emetic form : this is a food poisoning associated with S. aureus contaminated fried rice. (B). Diarrhea as: incubation period of 8-16 hours, diarrhea, cramping, no vomiting. 3rd Clostridium perfringens : spores resistant to heat sufficient in meat, poultry and legumes, incubation 8-14 hours, 24 hours of diarrhea and cramping abdominal disease, without vomiting or fever.

 

CHOLERA 

 

Etiology 

Vibrio cholerae serogroups OI (EI biotypes classical and Tor and O139 ).

 

 

Epidemiology 

Occur in the delta of the Ganges in the Indian subcontinent and South east Asia and sometimes in coastal areas of Texas and Louisiana: the spread of faecal contamination of water and food sources. Infection requires a large consumption of inoculation. toxin to cause disease symptoms. clinical symptoms.

 

Clinical Manifestations 

Incubation period of 24-48 hours following a painless diarrhea and vomiting, which can cause serious and rapid dehydration and death within hours. Rice water turbid liquid stool gray with patches of mucus.

 

Diagnosis .. stool  culture on selective medium  (e.g. TCBS agar). 

 

 

TREATMENT 

Rapid replacement of fluid, electrolytes and base with high sodium levels to correct the loss of Na in the stool or Ringer's lactate in patients with> 10% weight loss.Antibiotics can be used together, doxycycline, ciprofloxacin single dose of 1 g / d or erythromycin three divided doses for 3 days.

 

 

VIBRIO PARAHAEMOLTICUS AND NON - OI ,CHOLERA 

 

These infections are associated with the consumption or contaminated by sea water, badly seafood.After an incubation period of four hours to four days, darrhea aqueous, abdominal cramps, nausea, vomiting and sometimes fever and chills develop.The disease lasts 3-7 days and requires supportive care. Patients with comorbid illness (eg liver disease), sometimes extra-intestinal infections requiring antibiotics 

 

 

NORWALK VIRUS AND RELATED HUMAN CALCIVIRUSES 

 

 

These viruses are common causes of traveler's diarrhea and viral gastroenteritis in patients of all ages and epidemics worldwide, with U.S. higher prevalence in colder climates. Shellfish concentrate the virus by filtration and are at particular risk. Very small Inocults required for infection. Thus, although the fecal-oral route is the main form of transmisson, aerosol, fomites of contact, and person to person contact can cause an infection.

 

Clinical Manifestations 

After incubation period of 24 hours (range 12-72 hours). The patients experience sudden onset of nausea, vomiting, diarrhea or abdominal cramps with constitutional symptoms. the stool is soft, watery, without blood or mucus leukocytes. disease lasts 12 60 hours.

 

Treatment 

Only the necessary support measures. 

 

 

ROTA VIRUS 

 

Rotavirus is the leading cause of severe diarrhea in infants and young children, and is one of several viruses that cause infections, often called stomach flu, but not from the flu. It is a kind of double-stranded RNA virus in the family Reoviridae. At the age of five years, nearly all children worldwide have been infected with rotavirus at least once. But each infection, immunity develops, subsequent infections are less serious, and adults are rarely affected. There are five species of this virus, called A, B, C, D and E. A rotavirus, the most common causes of more than 90% of infections in humans.

Rotavirus is transmitted by fecal-oral contact with contaminated hands, surfaces and objects, and possibly by the respiratory route. The faeces of an infected person can contain more than 10 billion of infectious particles per gram, only 10-100 of them are required to transmit the infection to another person.

 

Clinical Manifestations 

Rotavirus gastroenteritis is a mild to severe illness characterized by vomiting, watery diarrhea and mild fever. When a child is infected with the virus has an incubation period of about two days before the onset of symptoms. Symptoms often start with vomiting, followed by four to eight days of severe diarrhea. Dehydration is more common than rotavirus infection in most of those caused by pathogenic bacteria, and is the most common cause of deaths related to rotavirus infection.

 

Diagnosis 

Enzymes immunoassays (EIAs ) or viral RNA detection  ,like PCR can identify this virus in sample of stool . 

 

Treatments 

Only necessary treatment is required .Antimotility agents should be avoided .

 

Prevention 

For prevention ,vaccine was withdrawn shortly after approval by the U.S . Drug and Food intake because it was causally linked to intussusception .

 

Diarrhea causes

Diarrhea in the 14 days called persistent diarrhea

INFECTIOUS  NON - INFLAMMATORY DIARRHEAS 

Diarrhea is a deviation from normal intestinal movements are characterized by increased stool frequency or liquidity, or both, often accompanied by an abnormal increase in stool weight per day (200 grams / day). It is classified as acute if the onset occurred within 14 days. Diarrhea in the 14 days called persistent, and beyond 30 days, is considered chronic. Diarrhea can be  recurrent diarrhea, infectious and noninfectious diarrhea, inflammatory diarrhea, which causes inflammation of the colon and diarrhea that are not lit noninflamatory colon.

There are different clinical settings where patients are more at risk than the general population of developing diarrhea. Babies in day care have an increased risk of infection by rotavirus, Giardia lamblia, and Campylobacter. Although HIV / AIDS patients may have atypical infections are most often infected with pathogens such as Escherichia coli usual. Cryptosporidiosis, Isospora belli, herpes simplex, Chlamydia trachomatis, Clostridium difficile, Shigella and other types of infection causes diarrhea in AIDS patients. Travelers are at risk from the bacterium E. enterotoxigenic E. coli, Rotavirus, Salmonella and Shigella.

Inflammatory diarrhea is suspected when patients present with acute diarrhea accompanied by bloody stools, fever, tenesmus, or abdominal pain. If the inflammation is in the colon, the stool is frequent and small in volume, whereas diarrhea due to small bowel inflammation is usually high in volume. In either case, stool leukocytosis is present, with more leukocytes the more distal the inflammation, as a rule. Infectious causes of inflammatory diarrhea include Salmonella, Shigella, Campylobacter, enterohemorrhagic E. coli, enteroinvasive E. coli, C. difficile, Entamoeba histolytica, and Yersinia. When inflammatory diarrhea is recurrent, noninfectious etiology should be suspected, such as Crohn's disease, ulcerative colitis, and radiation or ischemic colitis.

inflammatory diarrhea characterized by watery stools that may exceed 1 liter in volume, without symptoms suggestive of inflammation. It is caused by bacteria such as Vibrio cholerae, E coli and Staphylococcus food poisoning and Clostridium, viruses such as rotavirus and Norwalk virus and protozoa such as Cryptosporidium and Giardia. enterotoxins Many of these organizations and the development of interfering with the mechanism of absorption or secretion of diarrhea in the intestine, causing.

TRAVELER'S DIARRHEA 

People traveling in Asia, Africa and South and Central America 20 to 50% experience sudden onset of stomach cramps, loss of appetite and diarrhea. The disease usually begins within 3-5 days of arrival, containated associated with eating food or water, it takes 1-5 days, mostly due to enterotoxigenic Escherichia coli, subsalicylates bismuth can be used preventively. Liquefaction is usually adequate treatment, but if desired, 1-3 days during the fluoroquinolones can reduce the duration of illness is 24-36 hours. Antimotility agents can control diarrhea.

Chemotherapy protocols

Anti microbial ( antibiotics ) chemotherapy have had a major impact on life threatening infections 

ANTIMICROBIAL CHEMOTHERAPY PROTOCOLS

One of the greatest triumphs of modern medicine has been the introduction of a rational system of antimicrobial chemotherapy to fight against infectious diseases. Since time immemorial, people have used use mussels or mussel extracts to treat infections. In the early days of microbiology, an attempt was made to use extracts of fungal cultures to prevent infections of surgical wounds.

PRINCIPLES OF USE

Antibiotics are among the safest  of medicines, especially for  community infections, and a significant impact on life-threatening infections and reduce morbidity associated with many common infectious disease.This in turn is partly responsible for the overprescribing of these drugs, which led to concern about the increasing resistance to antibiotics.

Most antibiotic prescribing, particularly in the community, is empirical. While in hospital practice, microbiological documentation of the nature of infection and the sensitivity of the pathogen is not usually available for a day or two. the initial choice of treatment depends on clinical diagnosis and in turn a provisional microbiological diagnosis. This treatment "blind therapy targeting the pathogen most likely responsible for a specific syndrome, such as meningitis, urinary tract infection or pneumonia. Initial critically ill patients are often broad to cover the range of possible pathogens, but should be reduced when the microbiological data available.

BACTERICIDAL VERSUS BACTERIOSTATIC

In most infections there is no conclusive evidence that bactericidal drugs (penicillins, cepholosporins, aminoglycosides) are more effective than bacteriostatic drugs, but it is generally considered necessary to resort to the former i treat bacterial endocarditis in patients with mechanisms host defense are involved, particularly those with neutropenia. drug combinations are often necessary for reasons other providin spectrum covers - large. Initially Tuberculosis  is treated with three or four agents to avoid resistance to inhibition emerging.Synergistic is obtained through the use of penicillin and gentamicin in enterococcal endocarditis or gentamicin and ceftazidime in life - threatening Pseudomonas infection.

PHARMACOKINETIC FACTORS

To be successful enough to receive an antibiotic to penetrate the site of infection. Knowledge of standard pharmacokinetic aspects of absorption, distribution, metabolism and excretion of drugs have varied. difficult areas are the brain, eye and prostate cancer, but loculated abscesses are inaccssible most authors. Many of mild to moderate infections can be treated is compatible. Parenteral administration is reported seriously ill patients to ensure a rapid blood and tissue concentrations of antibiotics drug.Some only be administered parenterally, such as aminoglycosides and broad-spectrum cephalosporins. parenteral therapy is needed even to those who are unable to swallow or if gastrointestinal absorption is unreliable.

ANTIBIOTIC CHEMOPROPHYLAXIS

These are some indications the use of condoms antibiotics.These understand the conditions where the risk of infection is high (colon surgery), or the consequences of a severe infection (endocarditis, sepsis, post-splenectomy). The selection is determined by representatives of the likely risk of infectious disease and confirmed the efficacy and safety of treatment..... read more

Chemotherapy regimens

ANTIMICROBIAL CHEMOTHERAPY REGIMENS

DOSE AND DURATION OF THERAPY

This varies depending on the nature, severity, and response to therapy. The long-term treatment (up to 6 weeks) is required for some varieties of infective endocarditis when pulmnary tuberculosis were treated for at least 6 months. Treat many common infections, improvement occurs within 2-3 days, when the patient is afebrile or leukocytosis have been resolved, the mouth should be considered in these parenteral therapy.Five started seven days of therapy is sufficient for most infections. A short course of therapy (3 days or less) should these symptoms of uncomplicated bacteria (cystitis), minimizing the duration of treatment reduces the risk of side effects and super-infection of Candida spp or Clostridium difficile, as well as the cost of care. Breasts that concentrates in the cell, such as erythromycin, quinolones and tetracyclines are used in the treatment of mycoplasma, brucellosis, and Legionella infections.

RENAL AND HEPATIC INSUFFICIENCY

Many drugs require dose reduction of renal failure to prevent toxic buildup. This is particularly true beta lactums and aminoglycosides. Nalidixic acid and tetracycline, other doxycyclines, should be avoided. This hepatic impairment, caution and the dose should be reduced by agents such as isoniazid, ketoconazole, rifampin, and interferon.

THERAPEUTIC DRUG MONITORING

In order to ensure more non-toxic concentrations of therapeutic drugs, drugs such as aminoglycosides and vancomycin serum monitored, especially those with impared renal or change function.Peak (after 1 hour - the dose) and through the (pre-dose) on serum samples be tested. However, the increasing use of once daily doses of aminoglycosides, but the time randm serum analysis are being adopted.

MECHANISMS OF ACTION AND RESISTANCE TO ANTIMICROBIAL AGENTS 

Antibiotic works in different places for bacteria. Penecillin, cephalosporins and vancomycin, erythromycin cell wall and protein synthesis aminoglycosides, rifampicin effect on RNA synthesis and effect of metronidazole, quinolones and DNA synthesis. Sulfonamides and trimethoprim are folic acid antagonists and amphotericin B to prevent the synthesis of fungal sterols. Antibiotic resistance may be due to:

•  Failure to reach the target site, for example, because the causes of deterioration of permeability does not reach the outer membrane of    bacteria (eg, penicillin and Gram-negative).
•  Enzyme inactivation (eg, enzymes beta-lactamase).
•  Change the target site (eg, a point mutation in E. coli penicillin binding protien Strep.pneumoniae lead to resistance.

The development or acquisition of resistance to an antibiotic that the bacteria always involves either a mutation in a single point in a gene or transfer of genetic material from another organism. large fragments of DNA can be introduced into bacteria either by transfer of " naked " DNA or by a bacteriophage (a virus) DNA vector.Both the past (processing), and one (transduction) depend integration of new DNA into the chromosomal DNA recipient. This requires a high degree of homology between donor and recipient of the chromosomal DNA. Finally, resistance to antibiotics can be transferred from one bacterium to another by conjugation, where DNA extrachromosomal (plasmid) that contains resistance factor (R factor) is transferred from one cell to another by contact Direct. Transfer of these plasmids R factors can occur between unrelated bacterial strains and involve large amounts of DNA and often code for multiple resistance antbiotic.

The transformation is probably the least clinically relevant mechanism, while the transduction and transfer of R factors are generally responsible for the immediate emergence of antibiotic resistance in bacteria, increasing resistance to many antibiotics has developed...... read more 

What is a respiratory infection ?

This system is much more vulnerable to infections than other body parts

RESPIRATORY TRACT INFECTIONS

Respiratory infections are divided into upper respiratory tract infections and lower, separated by Carina. In health, the lower respiratory tract is normally sterile because of an extremely effective defense system. Upper respiratory tract infections are particularly common in the paranasal sinuses and childhood.The Middle ear structures are consistent and may be involved minor viral infections of lower respiratory nasopharynx.The is often compromised by smoking, pollution air, aspiration of airway secretions and chronic lung diseases, including chronic bronchitis and chronic obstructive pulmonary disease. Respiratory infections is defined clinical, radiological, sometimes, as in cases of pneumonia, and appropriate microbiological sampling.

The respiratory system is much more vulnerable to infection than other body parts. This is because it is easier for bacteria or viruses from entering the channel when someone breathes in. respiratory tract infections are more common during the winter. This is probably due to the winter people are more likely to stay in close contact with each other. Children tend to get more respiratory infections such as colds than adults. Because they have not yet developed immunity to many viruses that cause colds.

Respiratory infections are a common cause of the disease. Respiratory infection is most common cold. The respiratory system is a general term used to describe all parts of the body that are involved in helping a person to breathe. health professionals generally make a distinction between:

UPPER RESPIRATORY TRACT INFECTIONS
LOWER RESPIRATORY TRACT INFECTIONS

PATHOPHYSIOLOGY

The transmission of microorganisms responsible for the URI is produced aerosol droplets or direct contact with the hand in hand with infected secretions, including transport as a result of the nostrils or eyes. 7Thus, transmission occurs most often in crowded conditions. Direct invasion of respiratory epithelium results in symptoms compatible with the area (s) in question. sinusitis and acute bronchitis is often preceded by a cold. sinus allergies, anatomical abnormalities like a deviated septum, sinus ostium blockage caused by swelling of the mucosal immune disorders such as hypogammaglobulinemia and infection with human immunodeficiency virus, the abuse of cocaine and predispose to the development of acute sinusitis.

The majority of influenza epidemics, 20 century were caused by viruses, but few have been caused by influenza B. Most of the epidemics is believed to spread from students to their families. Annual influenza epidemics due to the supply of influenza virus mutants that most people have no immunity (antigenic drift). Pandemics, on the other hand, occur when a completely new influenza virus is transmitted to humans from other species, pigs and birds most common (antigenic shift). Persons aged 65 years and the underlying disease are at higher risk than healthy people to death and hospitalization due to worsening of their underlying disease as a result of influence....... read more