dr. ronald munthe - blok 17 - infeksi

8/15/2019 Dr. Ronald Munthe - Blok 17 - Infeksi

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INFECTION

dr. Ronald V Munthe SpOT


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Is a condition in which pathogenic

organism multiply and spread within the body tissues

Infection

Classical sign : Kalor, Rubor, Dolor, Tumor, O!


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Directly "ndirectly

Stab #ound, operation,open $racture

%lood stream &hematogen'(ose, mouth, bo#el, )* tract

+cute yogenic"n$ection

Chronic )ranulomatouReaction

Sub-acute hase

us&de$unct leucocytes, dead bacteria

tissue debris'

)ranuloma&lymphocyte, macrophage

giant cell'

type o$ in aderthe site o$ in$ectionthe host response


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Host susceptibility

Local Factor :• Trauma• Poor circulation• Sensiblity /• !oreign body &0'• Chronic bone or

1oint disease

Systemic factor • Malnutrition• Diabetes• Imunitas /• Debility


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cute 2aematogenous Osteomyeliti


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Common in children

+dults #ith special conditiondiabetes, immunocompromised, malnutrition, drug user

ost-traumatic e enthaematomes, 3uid collection

+cute 2aematogenous Osteomyelitis


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)ram 0 )ram -

Staphylococcus +ureus

Streptococcus yogenes

Streptococcus neumonia

2aemophylus "n3uen4a

5. Coli

seudomonas +erogenosa

roteus Miriabilis

%acteroides !ragilis



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"n3ammation

Resolution or"ntractable chronicity

Suppuration

(ecrosis

(e# %one !ormation

Characteristic attern



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Vascular congestione6udation o$ 3uid leucocyte in7ltration

+"(

intra-osseus pressure

"n3ammation



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Suppuration



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Suppuration



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intra-osseus pressure eriosteal Strippingascular stasis, thrombosis due to pus

Compromise blood supply

%one death

%acterial to6ins

0

se8uestra

(ecrosis



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Stripped periosteum Deep layer ne# bone $ormation

"n olucrum

5nclose the in$ected bone9 se8uestra

(e# %one !ormation



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Patogenesis (4)• Setelah 1 minggu terja i ne!rosis tulang

Se"uester#• Setelah $ minggu terbentu! tulang baru

ari periosteum yang terang!at in%olucrum#

• Pus mencari jalan !eluar membuat lubangyang isebut cloaca&fistel


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2 O li i


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2ealing

Remodelling

+ntibiotics 9 "ntraosseus decompression

(ormal bone contour

Resolution or"ntractable Chronicity


2 O li i


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Clinical !eatures

Re$use to use a ected limb

oo;S#elling

2yperaemiaus discharge

!eel

!ebris!luctuation

ain

Mo e

Not appear in early antibiotocs treatment

Tachicardia Tenderness

ymphadenopati2istory o$ in$ection



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Diagnostic "maging

Di gnostic


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Diagnostic"maging


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Diagnostic"maging


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Diagnostic


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USG Detect 3uid collection

Radioscintigraphy "ncreased acti ity in both phase

MRI & CTSensiti e

Di erentiateSo$t tissue in$ection 9 Osteomyelit

Sensiti e but not spesi7cBBmTc-2D

)a-citrate or === ln

Diagnostic"maging

Diagnostic


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Diagnostic"maging

Diagnostic


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Diagnostic"maging


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The most certain #ay to con7rmthe clinical diagnosis

is to aspirate pus $romthe metaphyseal subperiostealabscess or the ad1acent 1oint

us -

%acteroidal e6amination9

+ntibiotics sensiti ity


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aboratory


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Ehite cell count

C-Reacti e rotein

5SR

%lood Culture 0

aboratory

Di ti l Di


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Di erential Diagnose

Cellulitis

Streptococcal (ecroti4ing Myositis

+cute Suppurati e +rthritis

+cute Rheumatism


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Treatment

"$ osteomyelitis is suspected on clinical

grounds,blood and 3uid samples should be ta;enand then

treatment started immediately #ithout

#aiting$or 7nal con7rmation o$ the diagnosis


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Treatment Principles• Pro%i e analgesia ' lui Therapy• est affecte part (imobilisasi)•

I entify organism an gi%e antibiotic• Pus e%acuation an necrotic tissue• Stabili*e bone if it has fracture

Treatment


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Treatment

Surgical Drainage

Supporti e Treatment

Splintage

+ntibiotic Therapy

Treatment


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Supporti e Treatment

eat e t

+nalgesic

Septicaemia 9 !e er Dehydration

Treatment


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+ntibiotic Therapy

the prompt administrationo$ antibiotics is so ital, that treatment

should not a#ait the result

Ta;e the ‘best guest’

patientFs age, general state o$ resistance, renal $unction,degree o$ to6aemia and pre ious history o$ allergy

Must be ta;en into account

Treatment


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+ntibiotic Therapy

+dultsStaphylococcal

3uclo6acillin 9 $usidic acid

" . V &=-> #ee;s'

Oral &G- #ee;s'

Children2aemophylus

" . V

Oral

Cephalosporin&ce$uro6ime H ce$ota6ime'

+mo6ycla

Treatment


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Surgical Drainage

i$ the clinical $eatures do notimpro e #ithin G hours o$ starting treatment, or

e en

be$ore that i$ there are signs o$ deep pus &s#elling,oedema, 3uctuation', and most certainly i$ pus is

aspirated,the abscess should be drained by open operation

under general anaesthesiai$ there is an e6tensi e intramedullary abscess drainage can be better achie edby cutting a small #indo# in the corte6

Complication


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p

Metastatic "n$ection

Suppurati e +rthritis

+ltered %one )ro#th

Chronic Osteomyelitis


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Sub-+cute 2aematogenous

Osteomyelitis

presumably due tothe organism being less irulent orthe patient more resistant &or both'

Sub-+cute 2aematogenous Osteomyelitis


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Typically there is a #ell-de7ned ca ity incancellous bone, containing glairy seropurulent

3uid

The surrounding bone trabeculae are o$tenthic;ened

The ca ity is lined by granulation tissuecontaining a

mi6ture o$ acute and chronic in3ammatory

cells



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May ha e a limp and o$ten there isslight s#elling , muscle #asting and local

tenderness.

The temperature is usually normal and there is littleto

suggest an in$ection.

Clinical !eaturesain near one o$ the larger 1oints

$or se eral #ee;s or e en months



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The typical radiographic lesion is a circumscribed,round or o al Ica ityJ =-> cm in diameter,

most o$ten it is seenin the tibial or $emoral metaphysis

Sometimes the Fca ityF is surrounded by ahalo o$ sclerosis, the classic

Brodie'sabscess

The radioisotope scan sho#s

mar;edly increased acti ity

"ma g ing



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%iopsy is a gold standard $or diagnosis

The clinical and 6-ray appearancesmay resemble those

o$ an osteoid osteoma

"$ 3uid is encountered,it should be sent $or bacteriological culture



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immobili4ation and antibiotics&3uclo6acillin and $usidic acid' $or #ee;s usually result in healing

Curettage is also indicatedi$ the 6-ray sho#s that there is no

healinga$ter conser ati e treatment

Conser ati e

Treatment


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us

Se8uestra

Vascular Tissue

Sclerotic +rea

Sequestra & oreign implant act as substrate !or bacterial adhesion



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The patient presents becausepain, pyre6ia, redness andtenderness ha e recurred

&a F3areF' or #ith a discharging sinus

Clinical !eatures



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During acute 3ares the 5SR and blood #hite cell count

may be increased , these non-speci7c signs arehelp$ul

in assessing the progress o$ bone in$ectionbut they are not diagnostic

+ntistaphylococcal antibody titres may be

ele ateda aluable sign in the diagnosis o$ hiddenin$ections and in trac;ing progress to reco ery

"aboratory



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Treatment

+ntibioticsSeldom eradicate by antibiotics alone

Stop the spreading

Control the acute 3ares

Choice depends on bacteriological studies

Capable o$ penetrating sclerotic bone

(on-to6ic #ith long-term use



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Treatment

ocal Treatment

Sinus dressing

Colostomy paste

"ncission 9 Drainage $or acute abcess



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Treatment

OperationSigni7cant symptomsClear e idence o$ a se8uestrumor dead bone

+ll in$ected so$t tissue andall dead or de itali4ed bone

56cised

Dead material can be identi7ed by the preoperati e in1ectiono$ sulphan blue #hich stains all li ing tissues

green , lea ing dead material unstained



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Treatment



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Treatment

apineau Techni8ue!ill completely the dead space le$t a$ter e6cision o$ necrotictissue #ithli ing or potentially li ing material

Cancellous bone gra$t&autogenous'

+ntobiotic

0

!ibrin sealant

Muscle-3ap trans$er

Split s;in gra$t

ost Traumatic Osteomyelitis


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ost Traumatic Osteomyelitis

Staph. +ureus

The combination o$ tissue in1ury, ascular damage, oedema, haematoma, dead $ragments and

an open path#ay to the atmosphere

#ommon in adults


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e%erish an e%elops pain ans+elling o%er the $racture site , the +oun is

inflame

an there may be a seropurulent ischarge

Treatment : debridement, antibiotics, delayedwound closure

ost Operati e Osteomyelitis


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The true incidence is probably around L

considerably greater in the elderly, the obese, those #ith diabetes or other chronicdiseases, patients #ith sic;le-cell disease, )aucherFs disease orleu;aemia, patients on corticosteroid or immunosuppressi e

therapy, and patients #ho ha e hadmultiple pre ious operations at the same site

Organisms may be introduced directly into the#ound $rom the atmosphere, the instruments,

The patient or the surgeon

mi6ture o$ pathogenic bacteria$Staph, aureus, Proteus, E. coli, Pseudomonas%

&='so$t-tissue damage&>'haematoma $ormation

&G'%one death



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!oreign implant is both a predisposing$actor and an important element in its persistence.

%acteria as #ell as human tissue cells ha e an

a nity $or molecules on the sur$ace o$ the implant.%oth compete $or occupancy o$ the same sur$ace -the tissue cells by adaptation and integration , the

bacteria by adhesion and coloni4ation

Fthe race $or the sur$aceF$ ristina, ())%

5arly"ntermediate

ate

p y



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Septic arthritis• Septic arthritis- terja i a!ibat osteomielitis

pa a tulang metaphysis yang terleta! intracapsular

• Septic arthritis juga terja i a!ibat ino!ulasiba!teri langsung !e alam sen i ,misalnya trauma tembus !e alam sen i

atau infe!si menembus jaringan lempengepiphysis


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Septic arthritis


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Septic arthritis• Infe!si ba!teri yang menyerang jaringan

syno%ium an ruang & !apsul sen i yangmenga!ibat!an ber!umpulnya rea!si sel.sel PM/ an ilepas!annya en*ymproteoliti!


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Infe!si sen i• Septic arthritis• Septic bursitis• Infe!si pa a pasien pasca total Hip & !nee

replacement


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a!tor pre isposisi

• Peny sen i !ronis• Trauma• heumatio arthritis• Diabetes melitus• Terapi steroi• 0agal ginjal•

eganasan• Drug abuse

• i+ayat aspirasisen i & inje!si

• 0angguan &

insufisiensi %ascular• i+ayat infe!si sen i

sebelumnya


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Sen i pre ile!si

• 2utut 3 5• Hip $65• 7ahu 11 5• Si!u 185• 9rist : 5• ;n!le < 5

• Pre ile!si pa a ana! =

Paling sering sen i

lutut : 5Panggul $ 5


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uman penyebab• Staphylococcus aureus• Strepticoccus sp• 0ram negatif• Pnoumococcus


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uman penyebab

;na! i ba+ah $ th =Haemophylus influensa


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Tes iagnosti!

2ab =• 2eu!osit• 2>D ? $6

• ultur arah

(') 3 5


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Pemeri!saan ra iologi• Soft tissue = beng!a!• >ffusi cairan sensi

• @T scan

•

7one scan Tc ::


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Prinsip terapi• Menghambat multipli!asi !uman g

antibioti!• Drainage abses superiosteal ( bila su ah

terbentu! )


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Penatala!sanaan• ultur resistensi• ;ntibioti! intra %ena = $. 4 minggu• Aperasi rainage

Tuberculosis


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Tuberculosis(Tuberculosis Asteomyelitis)

• 7a!teri = Micobacterium Tuberculosa – Humanus roplet infection paru.paru – 7o%inus susu usus (jarang)

• Pathologyocus primer !ompleB primer (lesi paru '07 se!itar) ba!teri bisa orman i 07

bertahun.tahun#• Penyebaran Se!un er

7ila aya tahan tubuh ren ah T7@ milier iparu$&meningitis#

Penyebaran Tertier (1)


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Penyebaran Tertier (1)• Penyebaran i luar paru.paru terja i bertahun.tahun

setelah serangan pertama pre ile!si i %ertebralbo y an sen i syno%ial besar (panggul an lutut)#• 7a!teri bisa ari epiphyse !e syno%ial atau ari

syno%ial !e epiphyse atau bersamaan, oleh !arena

men apat nutrisi melalui pembuluh arah yangsama#


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Penyebaran Tertier ($)• Penyebaran tertier terja i bila aya tahan tubuh

menurun (nutrisi, penya!it !ronis)#• 7a!teri T7@ juga bisa menyerang iaphyse

phalanB (tuberculous actylitis)#• 7a!teri T7@ membentu! granuloma

!umpulan epitheloi an multi nucleate giantcell yg mengelilingi jaringan ne!rosis, isertailymphocyte pa a tepinya#


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0ejala linis• Pembeng!a!an an nyeri sen i

ter apat gangguan gera!#• 7erat ba an menurun#• /ight cry#

Spon ilitis T7@


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p @• Cmumnya aerah

thoracolumbal#• Penyebaran melalui

7atson s PleBus ari %ena

para%ertebral#

• 7a!teri umumnya menyerang


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a!te u u ya e ye a gbagian anterior %ertebral bo y osteoporosis an Se"uester

granulasi T7@ memenuhiperiosteum Para%ertebral ;bses ligamen longitu inalanterior an posterior oleh!arena iscus inter%ertebralisrelati%e !ebal, ma!a !erusa!anterja i pa a sta ium a!hir hasila!hir terja i !yphosis oleh !arena!olaps ari bagian anterior

%ertebral bo y 0ibus


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0ejala linis


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j• ;namnesa•

Pembuluh arah = 7S>mening!at, ifferentialcount, P@ T7@#

• E.ray• M I


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Therapy• ;nti T7@ $ 8H8>8 16 $H$• Apen operation fusi engan & tanpa

instrumen#

ompli!asi


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p• Pott s paraplegia•

Aleh !arena =1# Te!anan eBtra ural(pus, s"uester)

$# Penyebaran langsung

!e spinal cor

dr. ronald munthe - blok 17 - infeksi

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