° Question 1 of 59 v B oO ‘A 68 year old man with poorly controlled diabetes presents with severe otalgia and headaches. On examination, there is granulation tissue within the external auditory meatus. What is the most likely underlying infective agent? Streptococcus pyogenes Staphylococcus aureus ‘Actinomyces Bacteroides fragilis Malignant otitis externa is caused by Pseudomonas aeruginosa Severe pain, headaches and granulation tissue within the external auditory meatus are key features of malignant otitis externa. Diabetes mellitus is one of the commonest risk factors. | @ | Improve Malignant otitis externa * + Uncommon type of otitis externa that is found in immunocompromised individuals (90% cases found in diabetics) Infective organism is usually Pseudomonas aeruginosa * Infection commences in the soft tissues of the external auditory meatus, then progresses to involve the soft tissues and into the bony ear canal + Progresses to temporal bone osteomyelitis, Key features in history Diabetes (90%) or immunosuppression (iliness or treatment related) Severe, unrelenting, deep-seated otalgia ‘Temporal headaches Purulent otorthea Possibly dysphagia, hoarseness, and/or facial nerve dysfunction Treatment Anti pseudomonal antimicrobial agents Topical agents Hyperbaric oxygen Is sometimes used in refractory cases° Question 2 of 59 v 5 So ‘A 68 year old women with previous rheumatic fever is admitted with pyrexia of unknown origin. Her blood cultures are unhelpful but transoesophageal echocardiography reveals vegetations on the mitral valve. Infection with which of the following organisms is most likely? Staphylococcus aureus Streptococcus pyogenes Staphyloccus epidermidis ‘Staphylococcus saprophyticus This is the most common organism affecting previously abnormal heart valves. {« 9 | improve Surgical Microbiology * ‘An extensive topic so an overview is given here. Organisms causing common surgical infections are reasonable topics in the examination, However, microbiology Is less rigorously tested than anatomy, for example. ‘Common organisms ‘Staphylococcus aureus * Facultative anaerobe + Gram positive coccus ‘+ Haemolysis on blood agar plates * Catalase positive + 20% population are long term carriers ‘+ Exo and entero toxin may result in toxic shock syndrome and gastroenteritis respectively ‘+ Ideally treated with penicilin although many strains now resistant through beta Lactamase production. In the UK less than 5% of isolates are sensitive to penicilin, * Resistance to methicillin (and other antibiotics) is mediated by the mec operon , essentially penicillin binding protein is altered and resistance to this class of antibiotics ensues + Common cause of cutaneous infections and abscesses Streptococcus pyogenes * Gram positive, forms chain like colonies, Lancefield Group A Streptococcus + Produces beta haemolysis on blood agar plates ‘+ Rarely part of normal skin microflora + Catalase negative‘+ Releases a number of proteins/ virulence factors into host including hyaluronidase, streptokinase which allow rapid tissue destruction + Releases superantigens such as pyogenic exotoxin A which results in scarlet fever ‘+ Remains sensitive to penicillin, macrolides may be used as an alternative. Escherichia coli + Gram negative rod + Facultative anaerobe, non sporing * Wide range of subtypes and some are normal gut commensal + Some subtypes such as 0157 may produce lethal toxins resulting in haemolytic-uraemic syndrome. * Enterotoxigenic E-Coli produces an enterotoxin (ST enterotoxin) that results in large volume fluid secretion into the gut lumen (Via cGMP activation) + Enteropathogenic E-Coli binds to intestinal cells and cause structural damage, this coupled with a moderate (or in case of enteroinvasive E-Coll significant) invasive component produces enteritis and large volume diarthoea together with fever. + They are resistant to many antibiotics used to treat gram positive infections and acquire resistance rapidly and are recognised as producing beta lactamases Campylobacter jejuni + Curved, gram negative, non sporulating bacteria * One of the commonest causes of diarrhoea worldwide + Produces enteritis which is often diffuse and blood may be passed ‘+ Remains a differential for right iliac fossa pain with diarthoea * Self limiting infection so antibiotics are not usually advised. However, the quinolones are often rapidly effective Helicobacter pylori * Gram negative, helix shaped rod, microaerophillic *+ Produces hydrogenase that can derive energy from hydrogen released by intestinal bacteria * Flageliated and mobile * Those carrying the cag A gene may cause ulcers + Itssecretes urease that breaks down gastric urea> Carbon dioxide and ammonia> ammonium>bicarbonate (simplified!) The bicarbonate can neutralise the gastric acid. *+ Usually colonises the gastric antrum and irritates resulting in increased gastrin release and higher levels of gastric acid. These patients will develop duodenal ulcers. In those with more diffuse H-Pylori infection gastric acid levels are lower and ulcers develop by local tissue damage from H-Pylort these patients get gastric ulcers. * Diagnosis may be made by serology (approx. 75% sensitive). Biopsy urease test during endoscopy probably the most sensitive. * Inpatients who are colonised 10-20% risk of peptic ulcer, 1-2% risk gastric cancer, <1% risk MALT lymphoma. P eave mur nntac<) Question 3 of 59 v Bb © A 50-year-old female with a history of rheumatoid presents with a suspected septic knee joint. A diagnostic aspiration is performed and sent to microbiology. Which of the organisms below is most likely to be responsible? Staphylococcus epidermidis Escherichia coli Neisseria gonorrhoeae Streptococcus pneumoniae Septic arthritis - most common organism: Staphylococcus aureus | @ | Improve Septic arthritis * Overview ‘+ Most common organism overall Is Staphylococcus aureus ‘+ Inyoung adults who are sexually active Neisseria gonorrhoeae should also be considered Management + Synovial fluid should be obtained before starting treatment + Intravenous antibiotics which cover Gram-positive cocci are indicated. The BNF currently recommends flucloxaeillin or clindamycin if penicillin allergic * Antibiotic treatment is normally be given for several weeks (BNF states 6-12 weeks) + Needle aspiration should be used to decompress the joint + Arthroscopic lavage may be required Blas &A~ Save my noteseo Question 4 of 59 ea p Oo A young woman is admitted to hospital with E-coli 0157 after visiting Germany during an outbreak. Which of the following is not true of the condition? It may be complicated by micro-angiopathic haemolytic anaemia, oe Itis most commonly transmitted by consumption of contaminated food. oe Plasmids typically confer antibiotic resistance. Qo E-Coll is a gram negative organism, Children typically develop this complication. [ot [oe | improve | Bacterial Gastroenteritis * Causative organisms Features Campylobacter + Most common cause of acute infective diarrhoea Jejuni + Spiral, gram negative rods + Usually infects caecum and terminal ileum. Local lymphadenopathy is common ‘+ May mimic appendicitis as it has marked right iliac fossa pain ‘+ Reactive arthritis is seen in 1-2% of cases Shigella spp. ‘+ Members of the enterobacteriaceae + Gram negative bacilli + Clinically causes dysentery ‘+ Shigella soneil is the commonest infective organism (mild iliness) + Usually self limiting, ciprofioxacin may be required if individual is in a high risk group Salmonella + Facultatively anaerobic, gram negative, enterobacteriaceae spp + Infective dose varies according to subtype ‘+ Salmonellosis: usually transmitted by infected meat (especially poultry) and eggs.E.coli Yersinia enterocolitica Vibrio cholera LD | Search Search textbook * Enteropathogenic + Enteroinvasive: dysentery, large bowel necrosis/ulcers * Enterotoxigenic: small intestine, travelers diarrhoea + Enterohaemorrhagic: 0157, cause a haemorrhagic colitis, haemolytic uraemic syndrome and thrombotic thrombocytopaenic purpura * Gram negative, coccobacill! * Typically produces a protracted terminal lleitis that may mimic Crohns disease * Differential diagnosis acute appendicitis ‘+ May progress to septicaemia in susceptible individuals + Usually sensitive to quinolone or tetracyclines + Short, gram negative rods ‘+ Transmitted by contaminated water, seafood ‘+ Symptoms include sudden onset of effortless vorniting and profuse Watery diarrhoea + Correction of fluid and electrolyte losses are the mainstay of treatment + Most cases will resolve, antibiotics are not generally indicated > Tr By @ © Q Google search on “Bacterial Gastroenteritis” + suggeet link ‘# Suggest media Dashboard3° Question 5 of 59 v B ©} ‘A 28 year old lady is breast feeding her first child. She presents with discomfort of the right breast. Clinical examination demonstrates erythema and an area that is fluctuant. Aspiration and culture of the fluid is most likely to demonstrate infection with which of the following organisms? Lactobacillus casell Streptococcus pyogenes Staphylococcus epidermidis Actinomycosis Staphylococcus aureus Is the commonest cause. The infants mouth is usually the source as it damages the nipple areolar complex allowing entry of bacteria, @ | Improve Breast abscess * * Inlactational women Staphylococcus aureus Is the most common cause * Typical presentation is with a tender, fluctuant mass in a lactating women * Diagnosis and treatment is performed using USS and associated drainage of the abscess cavity. Antibiotics should also be administered + Where there is necrotic skin overlying the abscess, the patient should undergo surgery a Bo | Save my notes Search Search textbook B Q Google search on “Breast abscess"° Question 6 of 59 v Bp °o ‘A.32year old woman undergoes mastectomy and latissimus dorsi flap reconstruction for breast cancer, to provide optimal cosmesis a McGhan implant is placed under the myocutaneous flap. ‘Three weeks post operatively the patient continues to suffer from recurrent wound infections that have proved resistant to multiple courses of antibiotics. Which of the organisms listed below Is most likely to be responsible? Staphylococcus aureus ‘Streptococcus viridians ‘Streptococcus pyogenes ‘Staphylococcus saprophyticus This tends to colonise plastic devices and forms a biofilm which allows colonisation with other bacterial agents. itis notoriously difficult to eradicate once established and the usual treatment Is removal of the device. "| Improve Surgical Microbiology * ‘An extensive topic so an overview is given here, Organisms causing common surgical infections are reasonable topics in the examination. However, microbiology Is less rigorously tested than anatomy, for example. Common organisms Staphylococcus aureus + Facultative anaerobe *+ Gram positive coccus ‘+ Haemolysis on blood agar plates + Catalase positive + 20% population are long term carriers ‘+ Exo and entero toxin may result in toxic shock syndrome and gastroenteritis respectively ‘+ Ideally treated with penicilin although many strains now resistant through beta Lactamase production. in the UK less than 5% of isolates are sensitive to penicilin ‘+ Resistance to methicillin (and other antibiotics) is mediated by the mec operon , essentially penicillin binding protein is altered and resistance to this class of antibiotics ensues + Common cause of cutaneous infections and abscesses Streptococcus pyogenesStreptococcus pyogenes * Gram positive, forms chain like colonies, Lancefield Group A Streptococcus + Produces beta haemolysis on blood agar plates + Rarely part of normal skin microflora + Catalase negative ‘+ Releases a number of proteins/ virulence factors into host including hyaluronidase, streptokinase which allow rapid tissue destruction * Releases superantigens such as pyogenic exotoxin A which results in scarlet fever * Remains sensitive to penicillin, macrolides may be used as an alternative. Escherichia coli + Gram negative rod * Facultative anaerobe, non sporing * Wide range of subtypes and some are normal gut commensals * Some subtypes such as 0157 may produce lethal toxins resulting in haemolytic-uraemic syndrome. * Enterotoxigenic E-Coli produces an enterotoxin (ST enterotoxin) that results in large volume fluid secretion into the gut lumen (Via GMP activation) + Enteropathogenic E-Coli binds to intestinal cells and cause structural damage, this coupled with a moderate (or in case of enteroinvasive E-Coll significant) invasive component produces enteritis and large volume diarrhoea together with fever. + They are resistant to many antibiotics used to treat gram positive infections and acquire resistance rapidly and are recognised as producing beta lactamases Campylobacter jejuni * Curved, gram negative, non sporulating bacteria * One of the commonest causes of diarthoea worldwide * Produces enteritis which is often diffuse and blood may be passed * Remains a differential for right iliac fossa pain with diarrhoea * Self limiting infection so antibiotics are not usually advised. However, the quinolones are often rapidly effective, Helicobacter pylor! *+ Gram negative, helix shaped rod, microaerophllic, + Produces hydrogenase that can derive energy from hydrogen released by intestinal bacteria + Flagellated and mobile + Those carrying the cag A gene may cause ulcers + It secretes urease that breaks down gastric urea> Carbon dioxide and ammonia> ammonium>bicarbonate (simplified!) The bicarbonate can neutralise the gastric acid, + Usually colonises the gastric antrum and irritates resulting in increased gastrin release and higher levels of gastric acid. These patients will develop duodenal ulcers. In those with ‘more diffuse H-Pylorl infection gastric acid levels are lower and ulcers develop by local tissue damage from H-Pylor- these patients get gastric ulcers. + Diagnosis may be made by serology (approx. 75% sensitive). Biopsy urease test during endoscopy probably the most sensitive. + Inpatients who are colonised 10-20% risk of peptic ulcer, 1-2% risk gastric cancer, <1% risk MALT lymphoma(<) Question 7 of 59 v 6 ©} ‘A4 year old child presents with a 4-5 day history of feeling generally unwell and also of having a sore throat. On examination, there is marked cervical lymphadenopathy, the oropharynx is covered with a thick grey membrane which bleeds following attempted removal, What is the most likely diagnosis? Acute streptococcal pharyngitis Infection with Epstein Barr virus Ludwigs angina Ingestion of caustic soda Infection with diphtheria classically causes a systemic illness that lasts several days. The tonsils or pharynx can be covered in a thick grey membrane which bleeds on attempted removal. There is often quite marked cervical adenopathy and some individuals can have a bulls neck appearance. Death can occur through airway compromise, which is why the often described attempted removal of the pseudomembrane so beloved of examiners, Is, in practice rather a foolish thing to attempt in a young child! wo | P| Improve Acute tonsillitis * * Characterised by pharynaitis, fever, malaise and lymphadenopathy. * Over half of all cases are bacterial with Streptococcus pyogenes the most common. organism + The tonsils are typically oedematous and yellow or white pustules may be present * Infectious mononucleosis may mimic the condition. + Treatment with penicillin type antibiotics is indicated for bacterial tonsilitis. * Bacterial tonsiltis may result in local abscess formation (quinsy) Acute streptococcal tonsillitisAcute streptococcal tonsilitis ‘Search textbook Q Google search on “Acute tonsilitis” ‘+ Suggest tink suggest media Dashboard° Question 8 of 59 # ° A 23 year old lady has suffered from diarrhoea for 8 months, she has also lost 2 Kg in weight. At colonoscopy, appearances of melanosis coli are identified and confirmed on biopsy. What is the most likely cause? Ischaemic colitis o Salmonella gastroenteritis infection Ittitable bowel syndrome @ Clostridium difficile infection oe This may occur as a result of laxative abuse and consists of lipofuschin laden macrophages that appear brown. [oe | | improve Diarrhoea * World Health Organisation definitions Diarrhoea: > 3 loose or watery stool per day ‘Acute diarrhoea < 14 days Chronic diarrhoea > 14 days May be accompanied by abdominal pain or nausea/vomiting Classically causes left lower quadrant pain, diarrhoea and fever More common with broad spectrum antibiotics. Clostridium difficile is also seen with antibiotic use Ahistory of alternating diarrhoea and constipation may be given May lead to faecal incontinence in the elderly Chronic DiarrhoeaIrritable bowel syndrome Ulcerative colitis Crohn's disease Colorectal cancer Coeliac disease Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit. Patients may be divided into those with diarthoea predominant IBS and those with constipation predominant IBS. Features such as lethargy, nausea, backache and bladder symptoms may also be present Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common. Faecal urgency and tenesmus may occur Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative colitis. Other features include malabsorption, mouth ulcers perianal disease and intestinal obstruction Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss and anorexia * In children may present with failure to thrive, diarrhoea and abdominal distension + In adults lethargy, anaemia, diarthoea and weight loss are seen. Other autoimmune conditions may coexist Other conditions associated with diarrhoea include: + Thyrotoxicosis * Laxative abuse ‘+ Appendicitis with pelvic abscess or pelvic appendix + Radiation enteritis Diagnosis Stool culture Abdominal and digital rectal examination Consider colonoscopy (radiological studies unhelpful) Thyroid function tests, serum calcium, anti endomysial antibodies, glucose ‘Save my notes Search Search textbook. Q Google search on Diarrhoeaeo Question 9 of 59, v p So ‘A 34-year-old man from Zimbabwe is admitted with abdominal pain to the Emergency Department. An abdominal x-ray reveals urinary bladder calcification. What Is the most likely cause? ‘Schistosoma mansoni Sarcoidosis oe Leishmaniasis e Tuberculosis e Jem Schistosoma haematobium causes haematuria Schistosomiasis is the most common cause of bladder calcification worldwide, Schistosoma ‘mansoni typically resided in the colon from where itis excreted, %@ | Improve Schistosomiasis * Schistosomiasis, or bilharzia, is a parasitic flatworm infection. The following types of schistosomiasis are recognised + Schistosoma mansoni and Schistosoma intercalatum: intestinal schistosomiasis, ‘+ Schistosoma haematobium: urinary schistosomiasis, ‘Schistosoma haematobium This typically presents as a ‘swimmers itch’ in patients who have recently returned from Africa. Schistosoma haematobium is a risk factor for squamous cell bladder cancer Features = Frequency + Haematuria + Bladder calcification Management + Single oral dose of praziquantel° qusintoofss wl | A.22 year old lady is breastfeeding her first child. One week post partum she presents with a tender indurated mass in the right breast. Infection with which of the following is most likely? Streptococcus pyogenes Streptococcus bovis Klebsiella Streptococcus viridans staphylococcus aureus is the commonest cause of lactatlonal mastitis [| improve | Mastitis « Mastitis refers to infection within the breast, the commonest variant, lactational mastitis Is. related to breast feeding and occurs as a result of inoculation of the breast tissue (which may have breaks in epithelial integrity) with staphylococcus aureus that Is carried in the infants oropharynx. The result is a tender erythematous breast. Fever is common. Treatment is usually with encouraging breast drainage (e.g. breast pumps) and antibiotics. Imaging with USS will demonstrate any underlying abscess, The preferred treatment for this complication is percutaneous aspiration where this is possible. Where the overlying epithelium is non viable, debridement may be needed, there is a risk that this may be complicated by the development of a subsequent mammary duct fistula = Tr @ wo Save my notes ‘Search Search textbook B° Question 11 of 59 ¥ 5 So ‘23 year old man is admitted to hospital with diarrhoea and severe abdominal pain. He was previously well and his illness has lasted 18 hours. What is the likely cause? Laxative abuse Clostridium difficile Salmonella | commons et Ulcerative colitis Infection gastroenteritis infection ‘Severe abdominal pain tends to favour Campylobacter infection, [oe [oe | imorove Diarrhoea * World Health Organisation defi itions Diarrhoea: > 3 loose or watery stool per day Acute diarrhoea < 14 days Chronic diarrhoea > 14 days ‘Acute Diarrhoea Gastroenteritis, Diverticulitis Antibiotic therapy Constipation causing overflow Chronic Diarrhoea May be accompanied by abdominal pain or nausea/vomiting Classically causes left lower quadrant pain, diarrhoea and fever More common with broad spectrum antibiotics Clostridium difficile is also seen with antibiotic use Ahistory of alternating diarrhoea and constipation may be given May lead to faecal incontinence in the elderlyIrritable bowel syndrome Ulcerative colitis Crohn's disease Colorectal cancer Coeliac disease Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit. Patients may be divided into those with diarrhoea predominant IBS and those with constipation predominant IBS, Features such as lethargy, nausea, backache and bladder symptoms may also be present Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are ‘also common. Faecal urgency and tenesmus may occur Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative colitis. Other features include malabsorption, mouth ulcers perianal disease and Intestinal obstruction ‘Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss and anorexia + In children may present with failure to thrive, diarthoea and abdominal distension ‘+ In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other ‘autoimmune conditions may coexist Other conditions associated with diarrhoea include! + Thyrotoxicosis + Laxative abuse * Appendicitis with pelvic abscess or pelvic appendix * Radiation enteritis Stool culture ‘Abdominal and digital rectal examination Consider colonoscopy (radiological studies unhelpful) Thyroid function tests, serum calcium, anti endomysial antibodies, glucose Bile &-~ Search rt Tr & @ @ ii Search textbook go Q Gooale search on *Diarthoeat3° Question 12 of 59 v 5 © ‘A28 year old man undergoes a laparotomy for perforated duodenal ulcer and broad spectrum antibiotics are administered. Post operatively he has hearing impairment. Which of the following agents Is the most likely underlying culprit? Ciprofloxacin Metronidazole Ampieillin Cortrimoxazole Ototoxicity is a recog @ | Improve sd adverse reaction with the aminoglycoside antibiotics. Antibiotics: mechanism of action * The lists below summarise the site of action of the commonly used antibiotics Inhibit cell wall formation * penicillins + cephalosporins Inhibit protein synthesis + aminoglycosides (cause misreading of mRNA) + chloramphenicol + macrolides (e.g. erythromycin) + tetracyclines + fusidic acid Inhibit DNA synthesis + quinolones (e.g. ciprofloxacin) + metronidazole + sulphonamides + trimethoprim Inhibit RNA synthesis * rifampicin°o Question 13 of 59 ¥ F °o ‘A285 year old man returns from a backpacking holiday in India. He presents with symptoms of coughing and also of episodic abdominal discomfort. Perl anal examination Is normal. Stool microscopy demonstrates both worms and eggs within the faeces. What is the most likely Infective organism? Cryptosporidium Ancylostoma duodenale Clonorchis sinensis Enterobius vermicularis Infection with Ascaris lumbricoides usually occurs after individuals have visited places like sub ‘Saharan Africa or the far east. Unlike ancylostoma duodenale infection there is usually evidence of both worms and eggs in the stool. The absence of pruritus makes enterobius less likely. The presence of coughing may be due to the migration of the larva through the lungs. ee] =a Gastro intestinal parasitic infections * ‘Common infections Enterobiasis * Due to organism Enterobius vermicularis + Common cause of pruritus ani ‘+ Diagnosis usually made by placing scotch tape at the anus, this will ‘trap eggs that can then be viewed microscopically ‘+ Treatment is with mebendazole Ancylostoma + Hookworms that anchor in proximal small bowel duodenale ‘+ Most infections are asymptomatic although may cause iron deficiency anaemia * Larvae may be found in stools left at ambient temperature, otherwise infection is difficult to diagnose + Infection occurs as a result of cutaneous penetration, migrates to lungs, coughed up and then swallowed + Treatment is with mebendazoleAscariasis + Due to infection with roundworm Ascaris lumbricoides ‘Infections begin in gut following ingestion, then penetrate duodenal ‘wall to migrate to lungs, coughed up and swallowed, cycle begins again + Diagnosis is made by identification of worm or eggs within faeces + Treatment is with mebendazole Strongyloidiasis + Due to infection with Strongyloides stercoralis + Rare in west + Organism is a nematode living in duodenum of host ‘+ Initial infection is via skin penetration. They then migrate to lungs and are coughed up and swallowed. Then mature in small bowel are excreted and cycle begins again + Anauto infective cycle is also recognised where larvae will penetrate colonic wall ‘+ Individuals may be asymptomatic, although they may also have respiratory disease and skin lesions + Diagnosis is usually made by stool microscopy ‘+ In the UK mebendazole is used for treatment + Protozoal infection + Organisms produce cysts which are excreted and thereby cause new infections ‘+ Symptoms consist of diarthoea and cramping abdominal pains. ‘Symptoms are worse in immunosuppressed people + Cysts may be identified in stools ‘+ Treatment is with metronidazole Giardiasis + Diarrhoeal infection caused by Giardia lamblia (protozoan) ‘+ Infections occur as a result of ingestion of cysts ‘+ Symptoms are usually gastrointestinal with abdominal pain, bloating and passage of soft or loose stools. + Diagnosis is by serology or stool microscopy ‘+ First line treatment is with metronidazole Bleu- Tr By @ @ [Savers |Oo Question 14 of 59 Which of the following statements relating to osteomyelitis is false? Is the result of haematogenous spread in most cases Isdue to Staphylococcus aureus Plain radiographs may be normal in the early stages The presence of associated septic joint involvement will significantly alter management in 50% cases ° Itis managed medically in the first instance (with an antistaphylococcal antibiotic). This differs from the situation in septic joints where early joint washout is mandatory. @ | Improve Osteomyelitis * Infection of the bone Causes ‘+ S.aureus and occasionally Enterobacter or Streptococcus species + Insickle cell: Salmonella species Clinical features + Erythema * Pain + Fever Investigation * X-ray; lytic centre with a ring of sclerosis + Bone biopsy and culture Treatment * Prolonged antibiotics + Sequestra may need surgical removal@_—___aestion 18 058 . 6 © ‘A.62 year old lady is unwell following a difficult acute cholecystectomy for acute cholecystitis. Her gallbladder spilled stones intraoperatively and she has been on ciprofloxacin intravenously for this for the past 4 days. She now has colicky abdominal pain and profuse, foul smelling dlarthoea. Which of the organisms below is likely to account for this illness? E-Coli Clostridium perfringens Clostridium tetani Campylobacter C. difficile may complicate administration of broad spectrum antibiotics. sé | | Improve vr Toes Surgical Microbiology * ‘An extensive topic so an overview is given here. Organisms causing common surgical infections ate reasonable topics in the examination. However, microbiology is less rigorously tested than anatomy, for example. ‘Common organisms Staphylococcus aureus + Facultative anaerobe * Gram positive coccus + Haemolysis on blood agar plates * Catalase positive + 20% population are long term carriers * Exo and entero toxin may result in toxic shock syndrome and gastroenteritis respectively * Ideally treated with penicillin although many strains now resistant through beta Lactamase production. In the UK less than 5% of Isolates are sensitive to penicillin. * Resistance to methicillin (and other antibiotics) is mediated by the mec operon , essentially penicillin binding protein is altered and resistance to this class of antibiotics ensues * Common cause of cutaneous infections and abscesses ‘Streptococcus pyogenes * Gram positive, forms chain like colonies, Lancefield Group A Streptococcus * Produces beta haemolysis on blood agar plates * Rarely part of normal skin microflora+ Catalase negative ‘+ Releases a number of proteins/ virulence factors into host including hyaluronidase, streptokinase which allow rapid tissue destruction * Releases superantigens such as pyogenic exotoxin A which results in scarlet fever * Remains sensitive to penicillin, macrolides may be used as an alternative. Escherichia coli + Gram negative rod * Facultative anaerobe, non sporing + Wide range of subtypes and some are normal gut commensals + Some subtypes such as 0157 may produce lethal toxins resulting in haemolytic-uraemic syndrome. + Enterotoxigenic E-Coli produces an enterotoxin (ST enterotoxin) that results in large volume fluid secretion into the gut lumen (Via CGMP activation) + Enteropathogenic E-Coli binds to intestinal cells and cause structural damage, this coupled with a moderate (or in case of enteroinvasive E-Coll significant) invasive component produces enteritis and large volume diarthoea together with fever. ‘+ They are resistant to many antibiotics used to treat gram positive infections and acquire resistance rapidly and are recognised as producing beta lactamases Campylobacter jejuni * Curved, gram negative, non sporulating bacteria + One of the commonest causes of diarrhoea worldwide + Produces enteritis which is often diffuse and blood may be passed * Remains a differential for right iliac fossa pain with diarrhoea * Self limiting infection so antibiotics are not usually advised. However, the quinolones are often rapidly effective. Helicobacter pylori * Gram negative, helix shaped rod, microaerophilic + Produces hydrogenase that can derive energy from hydrogen released by intestinal bacteria + Flagellated and mobile ‘+ Those carrying the cag A gene may cause ulcers * It secretes urease that breaks down gastric urea> Carbon dioxide and ammonia> ammonium»bicarbonate (simplified!) The bicarbonate can neutralise the gastric acid * Usually colonises the gastric antrum and irritates resulting in increased gastrin release and higher levels of gastric acid. These patients will develop duodenal ulcers. In those with more diffuse H-Pylorl infection gastric acid levels are lower and ulcers develop by local tissue damage from H-Pylor- these patients get gastric ulcers. + Diagnosis may be made by serology (approx. 75% sensitive). Biopsy urease test during endoscopy probably the most sensitive. ‘+ Inpatients who are colonised 10-20% risk of peptic ulcer, 1-2% risk gastric cancer, <1% risk MALT lymphoma. Bila &- Tr #y @ @e Question 16 of 59 v B © What is the mechanism of action of ciprofloxacin? Direct injury to the bacterial cell wall Inhibition of reverse transcriptase @Q ‘Osmotic damage to the cell oe @ oo Destruction of bacterial aquaporin proteins Improve Antibiotics: mechanism of action * The lists below summarise the site of action of the commonly used antibiotics Inhibit cell wall formation * penicillins * cephalosporins Inhibit protein synthesis, ‘+ aminoglycosides (cause misreading of mRNA) * chloramphenicol ‘+ macrolides (e.g. erythromycin) + tetracyclines * fusidie acid Inhibit DNA synthesis + quinolones (e.g. ciprofloxacin) ‘+ metronidazole + sulphonamides ‘+ trimethoprim Inhibit RNA synthesis + rifampicin° Question 17 of 58 v 5 So ‘14 year old boy presents with enlarged tonsils that meet in the midline. Oropharyngeal examination confirms this finding and you also notice petechial haemorrhages affecting the ‘oropharynx. On systemic examination he is noted to have splenomegaly. What is the most likely cause? Oral candidiasis, Infection with Streptococcus pyogenes Infection with Rickettsia rickettsii Infection with Staphylococcus aureus ‘A combination of pharyngitis and tonsilitis is often seen in glandular fever. Antibiotics containing Penicillin may produce a rash when given in this situation, leading to a mistaken label of allergy Infection with candidiasis can occur in individuals with systemic illness of which splenomegaly may be a feature. However, its unlikely to only affect the tonsils. | | Improve Acute tonsillitis * * Characterised by pharyngitis, fever, malaise and lymphadenopathy. * Over half of all cases are bacterial with Streptococcus pyogenes the most common organism + The tonsils are typically oedematous and yellow or white pustules may be present * Infectious mononucleosis may mimic the condition. * Treatment with penicillin type antibiotics is indicated for bacterial tonsillitis. + Bacterial tonsilltis may result in local abscess formation (quinsy) Acute streptococcal tonsillitisQo Question 19 of 59 v B ° In a 72 year old man undergoing a sigmoid colectomy for diverticular disease, which of the following Interventions is most likely to reduce his risk of developing a post operative wound Infection? Using a plain clear incise type drape to cover the operative field Administering mechanical bowel preparation pre operatively Shaving his abdominal wall one day prior to surgery | somncrtont ate sneorusndnecr antes potest None of the above ‘Administration of prophylactic antibiotics will reduce the risk of wound infection. Plain incise drapes increase the risk of wound infections and should not be used. lodophor impregnated drapes have been demonstrated to reduce the risk of wound infection. Shaving one day prior to surgery will increase the risk. we |e | improve Surgical site infection * = Surgical site infections may occur following a breach In tissue surfaces and allow normal commensals and other pathogens to initiate infection. They are a major cause of morbidity and mortality, + Surgical site infections (SS!) comprise up to 20% of all healthcare associated infections and at least 5% of patients undergoing surgery will develop an SSI as a result. + Inmany cases the organisms are derived from the patient's own body. Measures that may Increase the risk of SSI include: + Shaving the wound using a razor (disposable clipper preferred) ‘+ Using a non iodine impregnated incise drape if one Is deemed to be necessary + Tissue hypoxia + Delayed administration of prophylactic antibiotics in tourniquet surgery Preoperatively * Don't remove body hair routinely * If hair needs removal, use electrical clippers with single use head (razors increase infection risk) + Antibiotic prophylaxis if: placement of prosthesis or valve ~clean-contaminated surgery ~ contaminated surgery* Use local formulary * Aim to give single dose IV antibiotic on anaesthesia * Ifa tourniquet is to be used, give prophylactic antibiotics earlier Intraoperatively *+ Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI) * Cover surgical site with dressing * Arecent meta analysis has confirmed that administration of supplementary oxygen does not reduce the risk of wound infection. In contrast to previous individual RCT's(1) + Wound edge protectors do not appear to confer benefit (2) Post operatively Tissue viability advice for management of surgical wounds healing by secondary intention Use of diathermy for skin incisions In the NICE guidelines the use of diathermy for skin incisions is not advocated(3). Several randomised controlled trials have been undertaken and demonstrated no increase in risk of SSI when diathermy is used(4). References 1. Brar M et al.. Perioperative supplemental oxygen in colorectal patients: a meta analysis. J Surg Res 2011 (166): 227 -235. 2. Pinkney T et al. Impact of wound edge protection devices on surgical site infection after laparotomy: impact of a multicentre randomised controlled trial (ROSSINI Trial). BMJ 2013 (347):10, 3. http://www.nice.org.uk/CG74 4, Ahmad N and Ahmed A. Meta-analysis of the effectiveness of surgical scalpel or diathermy in making abdominal skin incisions. Ann Surg 2011, 253(1):8-13. Bile &- Save my notes Search Search textbook GB ‘Q Google search on “Surgical site infection” Suggest Ink FSuggest media3° Question 20 of 59 ¥ 8 ° 30 year old ald worker becomes unwell whilst helping at the scene of a recent earthquake. He develops vomiting and soon afterwards a diarthoea that Is loose and extremely watery. What Is the most likely infective organism? Campylobacter jejuni eo Enterohaemorragic E Coli e Clostridium perfringens eo Clostridium boltulinum eo The passage of very loose and watery stools distinguishes cholera. Most gastroenteric infections do not produce such watery motions @ | @ | Improve Bacterial Gastroenteritis * Causative organisms. Features Campylobacter» Most common cause of acute infective diarthoea Jejuni + Spiral, gram negative rods + Usually infects caecum and terminal ileum. Local lymphadenopathy is common ‘+ May mimic appendicitis as it has marked right iliac fossa pain + Reactive arthritis is seen in 1-2% of cases Shigella spp. ‘+ Members of the enterobacteriaceae + Gram negative bacilli + Clinically causes dysentery ‘+ Shigella sonell is the commonest infective organism (mild illness) + Usually self limiting, ciprofloxacin may be required if individual is in a high risk group Salmonella + Facultatively anaerobic, gram negative, enterobacteriaceae spp + Infective dose varies according to subtype ‘+ Salmonellosis: usually transmitted by infected meat (especially poultry) and eggsE. coll + Enteropathogenic + Enteroinvasive: dysentery, large bowel necrosis/ulcers + Enterotoxigenic: small intestine, travelers diarrhoea + Enterohaemorrhagic: 0157, cause a haemorrhagic colitis, haemolytic Uuraemic syndrome and thrombotic thrombocytopaenic purpura Yersinia + Gram negative, coccobacilli enterocolitica + Typically produces a protracted terminal ileitis that may mimic Crohns disease + Differential diagnosis acute appendicitis, + May progress to septicaemia in susceptible individuals + Usually sensitive to quinolone or tetracyclines Vibrio cholera + Short, gram negative rods + Transmitted by contaminated water, seafood + Symptoms include sudden onset of effortless vomiting and profuse watery diarrhoea + Correction of fluid and electrolyte losses are the mainstay of treatment + Most cases will resolve, antibiotics are not generally indicated Search textbook. B Q Google search on "Bacterial Gastroenteritis” Suggest tink FSuggest media Dashboard(<) Question 21 of 59 ¥ p °° ‘A.48 year old lady is admitted with crampy abdominal pain and diarrhoea. She has been unwell for the past 12 hours. in the history she complains that her milk bottles have been pecked repeatedly by birds, she otherwise has had no dietary changes. Which of the following is the most likely causative organism? ‘Staphylococcus aureus Clostridium difficile @ eo Norovirus Qe eS Clostridium botulinum Birds are a recognised reservoir of campylobacter. Bacterial Gastroenteritis * Causative organisms. Features Campylobacter + Most common cause of acute infective diarrhoea Jejuni * Spiral, gram negative rods + Usually infects caecum and terminal ileum. Local lymphadenopathy Is common + May mimic appendicitis as It has marked right iliac fossa pain + Reactive arthritis is seen in 1-2% of cases Shigella spp. ‘+ Members of the enterobacteriaceae + Gram negative bacilli * Clinically causes dysentery + Shigella soneit is the commonest infective organism (mild illness) + Usually self limiting, ciprofloxacin may be required if individual is in a high risk group Salmonella + Facultatively anaerobic, gram negative, enterobacteriaceae spp + Infective dose varies according to subtype + Salmonellosis: usually transmitted by infected meat (especially poultry) and eggsE.coli + Enteropathogenic ‘+ Enteroinvasive: dysentery, large bowel necrosis/ulcers * Enterotoxigenic: small intestine, travelers diarthoea + Enterohaemorthagic: 0157, cause a haemorrhagic colitis, haemolytic uraemic syndrome and thrombotic thrombocytopaenic purpura Yersinia * Gram negative, coccobacili enterocolitica * Typically produces a protracted terminal lets that may mimic Crohns disease * Differential diagnosis acute appendicitis * May progress to septicaemia in susceptible individuals * Usually sensitive to quinolone or tetracyclines Vibrio cholera + Short, gram negative rods * Transmitted by contaminated water, seafood + Symptoms include sudden onset of effortless vomiting and profuse watery diarrhoea * Correction of fluid and electrolyte losses are the mainstay of treatment + Most cases will resolve, antibiotics are not generally indicated Tr gy @ @ Save my notes Search ‘Search textbook GB Q Google search on “Bacterial Gastroenteritis + Suggest ink 4 Suggest media Dashboard<) Question 22 of 59 v 5 oO ‘A22 year old man presents with a 5 day history of sore throat, malaise and fatigue. On examination, he has a large peritonsillar abscess. What Is the most likely underlying infective organism? Epstein Barr Virus: Cytomegalovirus Moraxella catarthalis Streptococcus viridans Quinsy usually occurs as a result of bacterial tonsilitis and the most common cause of bacterial tonsilltis is streptococcal organisms. 6 | | imorove | Acute tonsillitis * * Characterised by pharyngitis, fever, malaise and lymphadenopathy. ‘+ Over half of all cases are bacterial with Streptococcus pyogenes the most common organism ‘+ The tonsils are typically oedematous and yellow or white pustules may be present + Infectious mononucleosis may mimic the condition. ‘+ Treatment with penicillin type antibiotics is indicated for bacterial tonsilitis. ‘+ Bacterial tonsilitis may result in local abscess formation (quinsy) Acute streptococcal tonsillitisOo Question 23 of 59 v 5 >) ‘A22 year old man has undergone an inguinal hernia repair. Seven days later he presents with an erythematous and tender wound that is discharging a purulent material, What is the most likely cause? = eee TT @ Discharging haematoma @Q Infection with Pseudomonas eo Infection with Streptococcus pyogenes eo Infection with Bacteroides e In this setting Staphylococcus aureus infection is the most likely cause. In the UK between 2010, and 2011 the commonest cause of wound infection was enterobacter infections (usually following cardiac or colonic surgery). 23% of infections were due to Staph aureus, which fits the scenario above. Infection with the other organisms including strep pyogenes was much rarer. + Surgical site infection * - Surgical site infections may occur following a breach in tissue surfaces and allow normal ‘commensals and other pathogens to initiate infection. They are a major cause of morbidity and mortality, * Surgical site infections (SS!) comprise up to 20% of all healthcare associated infections and at least 5% of patients undergoing surgery will develop an SSI as a result, + Inmany cases the organisms are derived from the patient's own body. Measures that may increase the risk of SSI include: ‘+ Shaving the wound using a razor (disposable clipper preferred) + Using anon iodine impregnated incise drape if one is deemed to be necessary + Tissue hypoxia + Delayed administration of prophylactic antibiotics in tourniquet surgery Preoperatively + Don't remove body hair routinely * If hair needs removal, use electrical clippers with single use head (razors increase infection risk) * Antibiotic prophylaxis if - placement of prosthesis or valve - clean-contaminated surgery - contaminated surgeryUse local formulary * Aimto give single dose IV antibiotic on anaesthesia + Ifa tourniquet is to be used, give prophylactic antibiotics earlier Intraoperatively + Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI) + Cover surgical site with dressing + Arecent meta analysis has confirmed that administration of supplementary oxygen does not reduce the risk of wound infection. In contrast to previous individual RCT's(1) ‘+ Wound edge protectors do not appear to confer benefit (2) Post operatively Tissue viability advice for management of surgical wounds healing by secondary intention Use of diathermy for s ns In the NICE guidelines the use of diathermy for skin incisions is not advocated(3). Several randomised controlled trials have been undertaken and demonstrated no increase In risk of SSI when diathermy is used(4). References 1. Brar M et a.. Perioperative supplemental oxygen in colorectal patients: a meta analysis. J Surg Res 2011 (166): 227 -235. 2. Pinkney T et al. Impact of wound edge protection devices on surgical site infection after laparotomy: impact of a multicentre randomised controlled trial (ROSSINI Trial). BMJ 2013, (347):10. 3. http://www.nice.org.uk/CG74 4, Ahmad N and Ahmed A. Meta-analysis of the effectiveness of surgical scalpel or diathermy in making abdominal skin incisions. Ann Surg 2011, 253(1):8-13, Save my notes | Search Search textbook 'Q Google search on “Surgical site infection’ + Suggestink “# Suggest mecia<) Question 24 of 59 x Bp © A 54-year-old female is admitted one week following a cholecystectomy with profuse diarrhoea. Apart from a minor intra-operative bile spillage incurred during removal of the gallbladder, the procedure was uncomplicated. What is the most likely diagnosis? Campylobacter infection oe ‘Salmonella infection Pelvic abscess This Is a complex question, read the explanation below carefully. It tests two domains, firstly that bile spill is an indication for broad spectrum intravenous antibiotics and that this is a risk factor for clostridium difficile (which explains the diarrhea post antibiotic administration) ‘Antibioties are not routinely administered during an uncomplicated cholecystectomy. Indications for administration of broad spectrum antibiotics include intraoperative bile spillage. Delayed pelvic abscesses following bile spills are extremely rare since most surgeons will manage these intra-operatively. |e | imorove | Clostridium difficile * Clostridium difficile is a Gram positive rod often encountered in hospital practice. In the UK It can be found in 3% of normal adults and up to 66% of babies. It produces an exotoxin which causes intestinal damage leading to a syndrome called pseudomembranous colitis. Risk factors * Broad spectrum antibiotics * Use of PPI and H2 receptor antagonists * Contacted with persons infected with c.difficile Features Diarrhoea ‘Abdominal pain A raised white blood cell count Is characteristic ‘+ If severe, toxic megacolon may developDiagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool Management Firstine therapy is oral metronidazole for 10-14 days If severe, or not responding to metronidazole, then oral vancomycin may be used Patients who do not respond to vancomycin may respond to oral fidaxomicin Patients with severe and unremitting colitis should be considered for colectomy Search Search textbook GB Q Google search on “Clostridium difficile” “Suggest ink suggest medla Dashboard n 12 13 14 RISERS <7 RK eekSo Question 25 of 59 v Bp °o ‘A22 year old man presents with crampy abdominal pain diarthoea and bloating. He has just returned from a holiday in Egypt. He had been swimming in the local pool a few weeks ago. He reports that he Is opening his bowels 5 times a day. The stool floats in the tollet water, but there is no blood. What is the most likely cause? Cryptosporidium Salmonella sp Eccoli sp e Chronic pancreatitis e i — Giardia causes fat malabsorption, therefore greasy stool can occur. Itis resistant to chlorination, hence risk of transfer in swimming pools. & | P| Improve Diarrhoea * World Health Organisation definitions Diarrhoea: > 3 loose or watery stool per day Acute diarrhoea < 14 days Chronic diarrhoea > 14 days ‘Acute Diarrhoea Gastroenteritis May be accompanied by abdominal pain or nausea/vomiting Diverticulitis Classically causes left lower quadrant pain, diarrhoea and fever More common with broad spectrum antibiotics Clostridium difficile is also seen with antibiotic use Constipation causing A history of alternating overflow given May lead to faecal incontinence in the elderly Thoea and constipation may beChronic Diarrhoea Irritable bowel syndrome Ulcerative colitis Crohn's disease Colorectal cancer Coeliac disease Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit. Patients may be divided into those with diarrhoea predominant IBS and those with constipation predominant IBS. Features such as lethargy, nausea, backache and bladder symptoms may also be present Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common. Faecal urgency and tenesmus may occur Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative colitis. Other features include malabsorption, mouth ulcers perianal disease and intestinal obstruction ‘Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss and anorexia + Inchildren may present with failure to thrive, diarrhoea and abdominal distension ‘+ Inadults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune conditions may coexist Other conditions associated with diarrhoea include: * Thyrotoxicosis * Laxative abuse * Appendicitis with pelvic abscess or pelvic appendix * Radiation enteritis, Diagnosis Stool culture Abdominal and digital rectal examination Consider colonoscopy (radiological studies unhelpful) Thyroid function tests, serum calcium, anti endomysial antibodies, glucose mise g- iii Tr gy @ @ Save my notes |° Question 26 of 59 v B © ‘A 23 year old woman is admitted with sepsis and right loin pain. She has a history of a UTI that was treated by the GP with a course of trimethoprim that was commenced 24 hours previously. Which of the organisms listed below is the most likely cause? Bacteroides fragilis, Clostridium difficile Candida albicans Mycobacterium tuberculosis Ascending infection of the genitourinary tract is most commonly caused by E-Coli. Other organisms may be accountable, however, these are less common (4 [= [ore Surgical Microbiology * ‘An extensive topic so an overview Is given here. Organisms causing common surgical infections are reasonable topics in the examination. However, microbiology Is less rigorously tested than anatomy, for example. Common organisms Staphylococcus aureus + Facultative anaerobe + Gram positive coccus + Haemolysis on blood agar plates + Catalase positive ‘+ 20% population are long term carriers ‘+ Exo and entero toxin may result in toxic shock syndrome and gastroenteritis respectively *+ Ideally treated with penicillin although many strains now resistant through beta Lactamase production. In the UK less than 5% of isolates are sensitive to penicilin ‘+ Resistance to methicilin (and other antibiotics) is mediated by the mec operon , essentially Penicillin binding protein is altered and resistance to this class of antibiotics ensues + Common cause of cutaneous infections and abscesses Streptococcus pyogenes ‘+ Gram positive, forms chain like colonies, Lancefield Group A Streptococcus ‘+ Produces beta haemolysis on blood agar plates ‘+ Rarely part of normal skin microflora* Catalase negative ‘+ Releases a number of proteins/ virulence factors into host including hyaluronidase, streptokinase which allow rapid tissue destruction * Releases superantigens such as pyogenic exotoxin A which results in scarlet fever Remains sensitive to penicilin, macrolides may be used as an alternative, Escherichia coli * Gram negative rod * Facultative anaerobe, non sporing * Wide range of subtypes and some are normal gut commensals * Some subtypes such as 0157 may produce lethal toxins resulting in haemolytic-uraemic syndrome * Enterotoxigenic E-Coli produces an enterotoxin (ST enterotoxin) that results in large volume fluld secretion into the gut lumen (Via CGMP activation) + Enteropathogenic E-Coli binds to intestinal cells and cause structural damage, this coupled with a moderate (or in case of enteroinvasive E-Coli significant) invasive component produces enteritis and large volume diarthoea together with fever. * They are resistant to many antibiotics used to treat gram positive infections and acquire resistance rapidly and are recognised as producing beta lactamases Campylobacter jejuni * Curved, gram negative, non sporulating bacteria * One of the commonest causes of diarrhoea worldwide * Produces enteritis which is often diffuse and blood may be passed + Remains a differential for right iliac fossa pain with diarrhoea * Self limiting infection so antibiotics are not usually advised. However, the quinolones are often rapidly effective. Helicobacter pylori * Gram negative, helix shaped rod, microaerophillic + Produces hydrogenase that can derive energy from hydrogen released by intestinal bacteria * Flagellated and mobile + Those carrying the cag A gene may cause ulcers * It secretes urease that breaks down gastric urea> Carbon dioxide and ammonla> ammonium>bicarbonate (simplified!) The bicarbonate can neutralise the gastric acid * Usually colonises the gastric antrum and irritates resulting in increased gastrin release and higher levels of gastric acid, These patients will develop duodenal ulcers. In those with more diffuse H-Pylorl infection gastric acid levels are lower and ulcers develop by local tissue damage from H-Pylori- these patients get gastric ulcers. * Diagnosis may be made by serology (approx. 75% sensitive). Biopsy urease test during endoscopy probably the most sensitive. * Inpatients who are colonised 10-20% risk of peptic ulcer, 1-2% risk gastric cancer, <1% risk MALT lymphoma, Tr gy @ @eo Question 27 of 59 v Be ° What is the risk of a wound infection in a male undergoing a Hartmanns procedure for perforated sigmoid diverticular disease? | @ 15% 10% 20% 2 80% oe These infected cases carry a high risk of wound infection. In really heavily contaminated cases, ‘some surgeons do not close the skin at all. Even if antibiotics are given in this case, the infection rate will still be very high. | 8 | Improve Surgical site infection * - Surgical site infections may occur following a breach in tissue surfaces and allow normal ‘commensals and other pathogens to initiate infection. They are a major cause of morbidity and mortality. ‘+ Surgical site infections (SSI) comprise up to 20% of all healthcare associated infections and at least 5% of patients undergoing surgery will develop an SSI as a result. ‘+ Inmany cases the organisms are derived from the patient's own body. Measures that may increase the risk of SSI include: ‘+ Shaving the wound using a razor (disposable clipper preferred) ‘+ Using a non lodine impregnated incise drape if one Is deemed to be necessary + Tissue hypoxia + Delayed administration of prophylactic antibiotics in tourniquet surgery Preoperatively + Don't remove body hair routinely ‘+ If hair needs removal, use electrical clippers with single use head (razors increase infection risk) ‘+ Antibiotic prophylaxis if: - placement of prosthesis or valve - clean-contaminated surgery contaminated surgery + Use local formulary + Aim to give single dose IV antibiotic on anaesthesia‘+ Ifa tourniquet is to be used, give prophylactic antibiotics earlier Intraoperatively ‘+ Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SS!) + Cover surgical site with dressing * Arecent meta analysis has confirmed that administration of supplementary oxygen does not reduce the risk of wound infection. In contrast to previous individual RCT's(1) * Wound edge protectors do not appear to confer benefit (2) Post operatively Tissue viability advice for management of surgical wounds healing by secondary intention Use of diathermy for skin incisions In the NICE guidelines the use of diathermy for skin incisions is not advocated(3). Several randomised controlled trials have been undertaken and demonstrated no increase in risk of SSI when diathermy is used(4) References 1. Brar Met al, Perioperative supplemental oxygen in colorectal patients: a meta analysis. J Surg Res 2011 (166): 227-235. 2. Pinkney T et al. Impact of wound edge protection devices on surgical site infection after laparotomy: impact of a multicentre randomised controlled trial (ROSSINI Trial). BMJ 2013 (347):10 3. http://www.nice.org.uk/CG74 4, Ahmad N and Ahmed A. Meta-analysis of the effectiveness of surgical scalpel or diathermy in making abdominal skin incisions. Ann Surg 2011, 253(1):8-13. Save my notes Search Search textbook GB Q Google search on “Surgical site infection” + Suggest Ink uggest media<) Question 28 of 59 v B 2 A.34 year old male is admitted with diarthoea of 3 months duration. He is found to be HIV positive with a CD4 count <50. Which of the organisms listed below Is most likely to be responsible? iii = ‘Adenovirus Norovirus e Vibrio cholera eo Clostridium difficle oe Although a self limiting diarthoea is the norm, this is not the case in immunocompromised Individuals who can develop severe illness. Other organisms may include Salmonella, Shigella, and Campylobacter. | | improve Surgical Microbiology * ‘An extensive topic so an overview Is given here. Organisms causing common surgical infections are reasonable topics in the examination. However, microbiology is less rigorously tested than anatomy, for example. Common organisms ‘Staphylococcus aureus * Facultative anaerobe + Gram positive coccus + Haemolysis on blood agar plates * Catalase positive + 20% population are long term carriers + Exo and entero toxin may result in toxic shock syndrome and gastroenteritis respectively * Ideally treated with penicillin although many strains now resistant through beta Lactamase production. In the UK less than 5% of isolates are sensitive to penicillin. + Resistance to methicillin (and other antibiotics) is mediated by the mec operon , essentially Penicillin binding protein is altered and resistance to this class of antibiotics ensues + Common cause of cutaneous infections and abscesses ‘Streptococcus pyogenes + Gram positive, forms chain like colonies, Lancefield Group A Streptococcus * Produces beta haemolysis on blood aaar plates* Rarely part of normal skin microflora * Catalase negative * Releases a number of proteins/ virulence factors into host including hyaluronidase, streptokinase which allow rapid tissue destruction * Releases superantigens such as pyogenic exotoxin A which results in scarlet fever * Remains sensitive to penicillin, macrolides may be used as an alternative. Escherichia coll + Gram negative rod + Facultative anaerobe, non sporing * Wide range of subtypes and some are normal gut commensals ‘+ Some subtypes such as 0157 may produce lethal toxins resulting in haemolytic-uraemic syndrome + Enterotoxigenic E-Coli produces an enterotoxin (ST enterotoxin) that results in large volume fluid secretion into the gut lumen (Via cGMP activation) ‘+ Enteropathogenic E-Coli binds to intestinal cells and cause structural damage, this coupled with a moderate (or in case of enteroinvasive E-Coll significant) invasive component produces enteritis and large volume diarthoea together with fever. * They are resistant to many antibiotics used to treat gram positive infections and acquire resistance rapidly and are recognised as producing beta lactamases Campylobacter jejuni * Curved, gram negative, non sporulating bacteria * One of the commonest causes of diarthoea worldwide *+ Produces enteritis which is often diffuse and blood may be passed + Remains a differential for right ilac fossa pain with diarthoea + Self limiting infection so antibiotics are not usually advised. However, the quinolones are often rapidly effective Helicobacter pylori + Gram negative, helix shaped rod, microaerophillic * Produces hydrogenase that can derive energy from hydrogen released by intestinal bacteria + Flagellated and mobile * Those carrying the cag A gene may cause ulcers * It secretes urease that breaks down gastric urea> Carbon dioxide and ammonia> ‘ammonium>bicarbonate (simplified!) The bicarbonate can neutralise the gastric acid. + Usually colonises the gastric antrum and irritates resulting in increased gastrin release and higher levels of gastric acid. These patients will develop duodenal ulcers. In those with more diffuse H-Pylori infection gastric acid levels are lower and ulcers develop by local tissue damage from H-Pylor- these patients get gastric ulcers, + Diagnosis may be made by serology (approx. 75% sensitive). Biopsy urease test during endoscopy probably the most sensitive. + Inpatients who are colonised 10-20% risk of peptic ulcer, 1-2% risk gastric cancer, <1% risk MALT lymphoma, Bol -43m ii "eo Question 29 of 59 v ° A group of consultant surgeons are meeting at a symposium. The chef preparing the canapes has an infection on his finger. Approximately 40 minutes after eating the canapes the group are struck down with severe vomiting. What is the most likely underlying explanation for this process? | recwcotencctinton —stpteeanes rete = Presence of enterotoxin from ‘Streptococcus pyogenes in the food oe Infection with Campylobacter jejuni e Presence of enterotoxin from Clostridium perfringens in the food @ Infection with Shigella soneti Qe ‘Staphylococcus aureus may release an enterotoxin, this is preformed and thus will typically result in rapid onset of symptoms in affected individuals. of | @ | Improve Surgical Microbiology * An extensive topic so an overview is given here. Organisms causing common surgical infections are reasonable topics in the examination. However, microbiology is less rigorously tested than anatomy, for example. ‘Common organisms ‘Staphylococcus aureus + Facultative anaerobe * Gram positive coccus + Haemolysis on blood agar plates * Catalase positive + 20% population are long term carriers * Exo and entero toxin may result in toxic shock syndrome and gastroenteritis respectively + Ideally treated with penicillin although many strains now resistant through beta Lactamase production. In the UK less than 5% of isolates are sensitive to penicilin, + Resistance to methicillin (and other antibiotics) is mediated by the mec operon , essentlally Penicillin binding protein is altered and resistance to this class of antibiotics ensues * Common cause of cutaneous infections and abscesses ‘Streptococcus pyogenes * Gram positive, forms chain like colonies, Lancefield Group A Streptococcus + Produces beta haemolysis on blood agar plates+ Rarely part of normal skin microflora + Catalase negative ‘+ Releases a number of proteins/ virulence factors into host including hyaluronidase, streptokinase which allow rapid tissue destruction ‘+ Releases superantigens such as pyogenic exotoxin A which results in scarlet fever ‘+ Remains sensitive to penicillin, macrolides may be used as an alternative, Escherichia coll + Gram negative rod ‘+ Facultative anaerobe, non sporing ‘+ Wide range of subtypes and some are normal gut commensals ‘+ Some subtypes such as 0157 may produce lethal toxins resulting in haemolytic-uraemic syndrome + Enterotoxigenic E-Coli produces an enterotoxin (ST enterotoxin) that results in large volume fluid secretion into the gut lumen (Via CGMP activation) ‘+ Enteropathogenic E-Coli binds to intestinal cells and cause structural damage, this coupled with a moderate (or in case of enteroinvasive E-Coll significant) Invasive component produces enteritis and large volume diarrhoea together with fever. ‘+ They are resistant to many antibiotics used to treat gram positive infections and acquire resistance rapidly and are recognised as producing beta lactamases Campylobacter jejuni * Curved, gram negative, non sporulating bacteria * One of the commonest causes of diarrhoea worldwide * Produces enteritis which is often diffuse and blood may be passed * Remains a differential for right iliac fossa pain with diarrhoea * Self limiting infection so antibiotics are not usually advised. However, the quinolones are often rapidly effective. Helicobacter pylori * Gram negative, helix shaped rod, microaerophillic * Produces hydrogenase that can derive energy from hydrogen released by intestinal bacteria + Flagellated and mobile * Those carrying the cag A gene may cause ulcers * It secretes urease that breaks down gastric urea> Carbon dioxide and ammonia> ammonium>bicarbonate (simplified!) The bicarbonate can neutralise the gastric acid, * Usually colonises the gastric antrum and irritates resulting in increased gastrin release and higher levels of gastric acid. These patients will develop duodenal ulcers. In those with more diffuse H-Pylorl infection gastric acid levels are lower and ulcers develop by local tissue damage from H-Pylort- these patients get gastric ulcers. * Diagnosis may be made by serology (approx. 75% sensitive). Biopsy urease test during endoscopy probably the most sensitive. * Inpatients who are colonised 10-20% risk of peptic ulcer, 1-2% risk gastric cancer, <1% risk MALT lymphoma. Bieu- Tr & @ © iiee Question 30 of 59 v Bp © What Is the likely risk of surgical wound infection in a 23 year old male undergoing an elective inguinal hernia repair? Between 5 and 10% Between 10 and 15% More than 25% Between 15 and 20% This is a clean procedure and carries the lowest risk of SSI. That is why itis safe to use meshes in these settings. | | improve Ne Surgical site infection * - Surgical site infections may occur following a breach in tissue surfaces and allow normal ‘commensals and other pathogens to initiate infection. They are a major cause of morbidity and mortality. *+ Surgical site infections (SSI) comprise up to 20% of all healthcare associated infections and at least 5% of patients undergoing surgery will develop an SSI as a result. ‘+ Inmany cases the organisms are derived from the patient's own body. Measures that may Increase the risk of SSI include: ‘+ Shaving the wound using a razor (disposable clipper preferred) ‘+ Using a non iodine impregnated incise drape if one is deemed to be necessary + Tissue hypoxia + Delayed administration of prophylactic antibiotics in tourniquet surgery Preoperatively + Don't remove body hair routinely * If hair needs removal, use electrical clippers with single use head (razors increase infection risk) ‘Antibiotic prophylaxis if: placement of prosthesis or valve - clean-contaminated surgery ~ contaminated surgery + Use local formulary ‘+ Aim to give single dose IV antibiotic on anaesthesia + Ifa tourniquet is to be used, give prophylactic antibiotics earlierIntraoperatively ‘+ Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI) + Cover surgical site with dressing ‘+ Arecent meta analysis has confirmed that administration of supplementary oxygen does not reduce the risk of wound infection. In contrast to previous individual RCT's(1) ‘+ Wound edge protectors do not appear to confer benefit (2) Post operatively Tissue viability advice for management of surgical wounds healing by secondary intention Use of diathermy for skin incisions In the NICE guidelines the use of diathermy for skin incisions is not advocated(3). Several randomised controlled trials have been undertaken and demonstrated no increase in risk of SSI when diathermy is used(4). References 1. Brar M et al. Perioperative supplemental oxygen in colorectal patients: a meta analysis. J Surg Res 2011 (166): 227 -235. 2. Pinkney T et al. Impact of wound edge protection devices on surgical site infection after laparotomy: impact of a multicentre randomised controlled trial (ROSSINI Trial). BMJ 2013 (347):10 3. http://www.nice.org.uk/CG74 4. Ahmad N and Ahmed A. Meta-analysis of the effectiveness of surgical scalpel or diathermy in making abdominal skin incisions. Ann Surg 2011, 253(1):8-13. Roget Search Search textbook GB Q Google search on “Surgical site infection’ Suggest ink “Suggest media° Question 31 of 59 v BR © To which of the antibiotics listed below is streptococcus pyogenes stil largely susceptible to? Ciprofloxacin Tetracycline Sulphonamide o iis Metronidazole Penicillin is the antibiotic of choice for group A streptococcal infections. They are less susceptible to the other antibiotic types and the quinolones show variable responses | @ | improve Streptococci * Streptococci may be divided into alpha and beta haemolytic types Alpha haemolytic streptococci The most important alpha haemolytic streptococcus is Streptococcus pneumoniae (pneumococcus). Pneumococcus is a common cause of pneumonia, meningitis and otitis media, Another clinical example is Streptococcus viridans Beta haemolytic streptococci These can be subdivided into group A and B Group A. + most important organism is Streptococcus pyogenes * responsible for erysipelas, impetigo, cellulitis, type 2 necrotizing fasciitis and pharyngitis/tonsillitis ‘+ immunological reactions can cause rheumatic fever or post-streptococcal glomerulonephritis + erythrogenic toxins cause scarlet fever Group 8 * Streptococcus agalactiae may lead to neonatal meningitis and septicaemia° cueston 32 of 8 ¥ B >) ‘4.29 year old female undergoes a sub total thyroidectomy. Five days post operatively the wound becomes erythematous and discharges pus. What Is the most likely causative organism? Streptococcus pyogenes Haemophilus influenzae Pseudomonas aeruginosa Proteus mirabilis In this setting Staphylococcus aureus Infection is the most likely cause. In the UK between 2010 and 2011 the commonest cause of wound infection was enterobacter infections (usually following cardiac or colonic surgery). 23% of infections were due to Staph aureus, which fits the scenario above. Infection with the other organisms including strep pyogenes was much rarer, | improve Surgical site infection * - Surgical site infections may occur following a breach in tissue surfaces and allow normal commensals and other pathogens to initiate Infection. They are a major cause of morbidity and mortality. ‘+ Surgical site infections (SSI) comprise up to 20% of all healthcare associated infections and at least 5% of patients undergoing surgery will develop an SSI as a result. + Inmany cases the organisms are derived from the patient's own body. Measures that may Increase the risk of SSI include: ‘+ Shaving the wound using a razor (disposable clipper preferred) ‘+ Using a non iodine impregnated incise drape if one is deemed to be necessary + Tissue hypoxia + Delayed administration of prophylactic antibiotics in tourniquet surgery Preoperatively + Don't remove body hair routinely + If hair needs removal, use electrical clippers with single use head (razors increase infection risk) ‘+ Antibiotic prophylaxis if: ~ placement of prosthesis or valve - clean-contaminated surgery - contaminated surgery + Use local formulary+ Aim to give single dose IV antibiotic on anaesthesia + Ifa tourniquet is to be used, give prophylactic antibiotics earlier Intraoperatively * Prepare the skin with alcoholic chlorhexidine (Lowest incidence of SSI) + Cover surgical site with dressing * Arecent meta analysis has confirmed that administration of supplementary oxygen does not reduce the risk of wound infection. In contrast to previous individual RCT's(1) + Wound edge protectors do not appear to confer benefit (2) Post operatively Tissue viability advice for management of surgical wounds healing by secondary intention Use of diathermy for skin incisions In the NICE guidelines the use of diathermy for skin incisions is not advocated(3). Several randomised controlled trials have been undertaken and demonstrated no increase In risk of SSI when diathermy is used(4). References 1. Brar M et al.. Perioperative supplemental oxygen in colorectal patients: a meta analysis. J Surg Res 2011 (166): 227-235. 2. Pinkney T et al. Impact of wound edge protection devices on surgical site infection after laparotomy: impact of a multicentre randomised controlled trial (ROSSINI Trial). BMJ 2013 (347)10. 3. http://www.nice.org.uk/CG74 4, Ahmad N and Ahmed A. Meta-analysis of the effectiveness of surgical scalpel or diathermy in making abdominal skin incisions. Ann Surg 2011, 253(1):8-13. ‘Save my notes Search Search textbook. B Q Google search on “Surgical site infection’ + Suggest lnk ‘suggest media°o Question 33 of 59 ¥ p © ‘72 year old man with peripheral vascular disease develops a gangrenous toe. This becomes infected and there is evidence of infection in the surrounding tissues. On clinical palpation there is crepitus present within the tissues. What is the most likely infective organism? ‘Staphylococcus aureus ‘Streptococcus pyogenes Clostridium difficile Clostridium botulinum Clostridium perfringens is the most likely pathogen to be associated with gangrene. [ao [oe | improve Surgical Microbiology * An extensive topic so an overview is given here. Organisms causing common surgical infections are reasonable topics in the examination. However, microbiology is less rigorously tested than anatomy, for example. Common organisms Staphylococcus aureus * Facultative anaerobe + Gram positive coccus + Haemolysis on blood agar plates * Catalase positive + 20% population are long term carriers + Exo and entero toxin may result in toxic shock syndrome and gastroenteritis respectively * Ideally treated with penicillin although many strains now resistant through beta Lactamase production. In the UK less than 5% of isolates are sensitive to penicilin * Resistance to methicillin (and other antibiotics) Is mediated by the mec operon , essentially Penicillin binding protein is altered and resistance to this class of antibiotics ensues * Common cause of cutaneous infections and abscesses Streptococcus pyogenes ‘+ Gram positive, forms chain like colonies, Lancefield Group A Streptococcus + Produces beta haemolysis on blood agar plates. + Rarely part of normal skin microflora + Catalase negative+ Releases a number of proteins/ virulence factors into host including hyaluronidase, streptokinase which allow rapid tissue destruction * Releases superantigens such as pyogenic exotoxin A which results In scarlet fever + Remains sensitive to penicillin, macrolides may be used as an alternative. Escherichia coli * Gram negative rod * Facultative anaerobe, non sporing * Wide range of subtypes and some are normal gut commensals ‘+ Some subtypes such as 0157 may produce lethal toxins resulting in haemolytic-uraemic syndrome. + Enterotoxigenic E-Coli produces an enterotoxin (ST enterotoxin) that results in large volume fluid secretion Into the gut lumen (Via CGMP activation) + Enteropathogenic E-Coli binds to intestinal cells and cause structural damage, this coupled with a moderate (or in case of enteroinvasive E-Coli significant) invasive component produces enteritis and large volume diarthoea together with fever. ‘+ They are resistant to many antibiotics used to treat gram positive infections and acquire resistance rapidly and are recognised as producing beta lactamases Campylobacter jejunt + Curved, gram negative, non sporulating bacteria * One of the commonest causes of diarthoea worldwide * Produces enteritis which Is often diffuse and blood may be passed + Remains a differential for right iliac fossa pain with diarthoea + Self limiting infection so antibiotics are not usually advised. However, the quinolones are often rapidly effective, Helicobacter pylori ‘+ Gram negative, helix shaped rod, microaerophillic ‘+ Produces hydrogenase that can derive energy from hydrogen released by intestinal bacteria + Flagellated and mobile * Those carrying the cag A gene may cause ulcers * It secretes urease that breaks down gastric urea> Carbon dioxide and ammonia> ammonium>bicarbonate (simplified!) The bicarbonate can neutralise the gastric acid. + Usually colonises the gastric antrum and irritates resulting in increased gastrin release and higher levels of gastric acid. These patients will develop duodenal ulcers. in those with more diffuse H-Pylor! infection gastric acid levels are lower and ulcers develop by local tissue damage from H-Pylort- these patients get gastric ulcers. * Diagnosis may be made by serology (approx. 75% sensitive). Biopsy urease test during endoscopy probably the most sensitive. ‘+ Inpatients who are colonised 10-20% risk of peptic ulcer, 1-2% risk gastric cancer, <1% risk MALT lymphoma. Tr gy ml @ Save mv notes | a°o Question 34 of 59 v B © ‘A22 year old Chef presents with abdominal pain in the right ilac fossa. There is an associated temperature and diarrhoea. The CT1 takes the patient to theatre for an appendicectomy, but the ‘appendix appears normal. The terminal ileum appears thickened and engorged. Infection with which of the following is most likely? ee @ Yersinia pestis Salmonella @ Vibrio cholera oe Entero invasive E Coli Qe Yersinia can be mistaken for acute appendicitis due to mesenteric lymphadenitis and lleltis, Yersinia infection of the terminal ileum typically produces more marked clinical changes of this segment of bowel than infection with campylobacter. Yersinia pestis causes plague, @ | F | Improve Bacterial Gastroenteritis * Causative organisms: Features Campylobacter + Most common cause of acute infective diarrhoea Jejuni * Spiral, gram negative rods * Usually infects caecum and terminal ileum. Local lymphadenopathy 's common + May mimic appendicitis as it has marked right iliac fossa pain * Reactive arthritis is seen in 1-2% of cases Shigella spp. + Members of the enterobacteriaceae * Gram negative bacilli * Clinically causes dysentery * Shigella soneii is the commonest infective organism (mild illness) + Usually self limiting, ciprofloxacin may be required if individual is in a high risk group Salmonella + Facultatively anaerobic, gram negative, enterobacteriaceae spp * Infective dose varies according to subtype‘+ Salmonellosis: usually transmitted by infected meat (especially poultry) and eggs E.coli + Enteropathogenic + Enteroinvasive: dysentery, large bowel necrosis/ulcers + Enterotoxigenic: small intestine, travelers diarrhoea + Enterohaemorthagic: 0157, cause a haemorrhagic colitis, haemolytic Uuraemic syndrome and thrombotic thrombocytopaenic purpura Yersinia + Gram negative, coccobacilli enterocolitica + Typically produces a protracted terminal ileitis that may mimic Crohns disease + Differential diagnosis acute appendicitis, ‘+ May progress to septicaemia in susceptible individuals + Usually sensitive to quinolone or tetracyclines Vibrio cholera + Short, gram negative rods + Transmitted by contaminated water, seafood ‘+ Symptoms include sudden onset of effortless vomiting and profuse watery diarrhoea + Correction of fluid and electrolyte losses are the mainstay of treatment ‘+ Most cases will resolve, antibiotics are not generally indicated Tr gy @ @ [Save myn] Search Search textbook B Q Google search on "Bacterial Gastroenteritis” “+ Suggest lnk Suggest media6 Question 35 of 59 x Bb So ‘A 6 year old boy presents with symptoms of recurrent pruritus ani. On examination, there Is evidence of a small worm like structure protruding from the anus. What is the most likely infective organism? Echinococcus granulosus ides Ancylostoma duodenale Clonorchis sinensis Infection with enterobius is extremely common. Pruritus is the main symptom, as there is a lack of tissue invasion itis rare for individuals to have any signs of systemic sepsis. Improve Gastro intestinal parasitic infections * Common infections Enterobiasis : Ancylostoma . duodenale . Ascariasis : Due to organism Enterobius vermicularis Common cause of pruritus ani Diagnosis usually made by placing scotch tape at the anus, this will trap eggs that can then be viewed microscopically Treatment is with mebendazole Hookworms that anchor in proximal small bowel ‘Most infections are asymptomatic although may cause iron deficiency anaemia Larvae may be found in stools left at ambient temperature, otherwise infection is difficult to diagnose Infection occurs as a result of cutaneous penetration, migrates to lungs, coughed up and then swallowed Treatment is with mebendazole Due to infection with roundworm Ascaris lumbricoides Infections begin in gut following ingestion, then penetrate duodenal wall to migrate to lungs, coughed up and swallowed, cycle begins again+ Diagnosis is made by identification of worm or eggs within faeces + Treatment is with mebendazole Strongyloidiasis + Due to infection with Strongyloides stercoralis + Rare in west + Organism is a nematode living in duodenum of host + Initial infection is via skin penetration. They then migrate to lungs, and are coughed up and swallowed. Then mature in small bowel are excreted and cycle begins again + An auto infective cycle is also recognised where larvae will penetrate colonic wall + Individuals may be asymptomatic, although they may also have respiratory disease and skin lesions + Diagnosis Is usually made by stool microscopy + In the UK mebendazole Is used for treatment + Protozoal infection + Organisms produce cysts which are excreted and thereby cause new infections «Symptoms consist of diarrhoea and cramping abdominal pains. ‘symptoms are worse in immunosuppressed people + Cysts may be identified in stools ‘= Treatment is with metronidazole Giardiasis + Diarrhoeal infection caused by Giardia lamblia (protozoan) + Infections occur as a result of ingestion of cysts + Symptoms are usually gastrointestinal with abdominal pain, bloating and passage of soft or loose stools + Diagnosis is by serology or stool microscopy + First line treatment is with metronidazole mre: [seve myroes | Search Search textbook. Q Google search on “Gastro intestinal parasitic infectionsie) cuestion 26.0859 e rp Oo) A surgical trainee is incising a groin ‘abscess’ in an intravenous drug abuser. Unfortunately the ‘abscess’ |s a false aneurysm and torrential bleeding ensues. In the panic of the situation the doctor then stabs himself in the finger. It transpires that the patient is a Hepatitis 8 carrier and the doctor is not immunised! What type of virus is Hepatitis 87 Single stranded DNA virus Double stranded RNA virus Single stranded RNA virus Retrovirus #9 | Improve Hepatitis B « Hepatitis B is a double-stranded DNA virus and is spread through exposure to infected blood or body fluids, including vertical transmission from mother to child. The incubation period Is 6-20 weeks. Immunisation against hepatitis 8 Contains HBsAg absorbed onto aluminium hydroxide adjuvant and is prepared from yeast cells using recombinant DNA technology Most schedules give 3 doses of the vaccine with a recommendation for a one-off booster 5 years following the initial primary vaccination At risk groups who should be vaccinated include: healthcare workers, intravenous drug users, sex workers, close family contacts of an individual with hepatitis B, individuals receiving blood transfusions regularly, chronic kidney disease patients who may soon require renal replacement therapy, prisoners, chronic liver disease patients Around 10-15% of adults fail to respond or respond poorly to 3 doses of the vaccine. Risk factors include age over 40 years, obesity, smoking, alcohol excess and immunosuppression Testing for anti-HBs is only recommended for those at risk of occupational exposure (Le. Healthcare workers) and patients with chronic kidney disease. In these patients anti: HBs levels should be checked 1-4 months after primary immunisation The table below shows how to interpret anti-HBs levels:Anti- Response HBs level (miu/ml) >100 Indicates adequate response, no further testing required. Should still receive booster at 5 years 10-100 Suboptimal response - one additional vaccine dose should be given. If immunocompetent no further testing is required <10 Non-tesponder. Test for current or past infection. Give further vaccine course (Le. 3 doses again) with testing following. If stil fails to respond then HBIG would be required for protection if exposed to the virus Complications of hepatitis B infection + Chronic hepatitis (5-10%) ‘* Fulminant liver failure (1%) + Hepatocellular carcinoma + Glomerulonephritis * Polyarteritis nodosa + Cryoglobulinaemia Management of hepatitis B + Pegylated interferon-alpha used to be the only treatment available. It reduces viral replication in up to 30% of chronic carriers. A better response is predicted by being female, < 50 years old, low HBV DNA levels, non-Asian, HIV negative, high degree of inflammation on liver biopsy + However, due to the side-effects of pegylated interferon itis now used less commonly in clinical practice. Oral antiviral medication is increasingly used with an aim to suppress viral replication (not in dissimilar way to treating HIV patients) + Examples include lamivudine, tenofovir and entecavir [savers Search Search textbook B Q Google search on "Hepatitis B°° Question 37 of 59 x 8 © A 58 year old man undergoes a difficult colonoscopy for assessment of a caecal cancer. 48 hours after the procedure he is admitted with septicaemia. His abdomen is soft and non tender. Blood cultures grow gram positive cocci. What is the most likely underlying organism? | Streptococcus pyogenes Qo =a © Clostridium difficle @e Bacteroides fragilis oS Streptococcus bovis septicaemia is associated with carcinoma of the colon. Itcan also cause endocarditis. Improve Surgical Microbiology * ‘An extensive topic so an overview is given here. Organisms causing common surgical infections are reasonable topics in the examination. However, microbiology is less rigorously tested than anatomy, for example. Common organisms Staphylococcus aureus + Facultative anaerobe * Gram positive coccus + Haemolysis on blood agar plates * Catalase positive + 20% population are long term carriers + Exo and entero toxin may result in toxic shock syndrome and gastroenteritis respectively + Ideally treated with penicilin although many strains now resistant through beta Lactamase production. in the UK less than 5% of isolates are sensitive to penicillin. * Resistance to methicillin (and other antibiotics) is mediated by the mec operon , essentially Penicillin binding protein is altered and resistance to this class of antibiotics ensues + Common cause of cutaneous infections and abscesses Streptococcus pyogenes + Gram positive, forms chain like colonies, Lancefield Group A Streptococcus * Produces beta haemolysis on blood agar plates * Rarely part of normal skin microflora* Catalase negative + Releases a number of protelns/ virulence factors into host including hyaluronidase, streptokinase which allow rapid tissue destruction + Releases superantigens such as pyogenic exotoxin A which results in scarlet fever + Remains sensitive to penicilin, macrolides may be used as an alternative. Escherichia coli + Gram negative rod ‘+ Facultative anaerobe, non sporing ‘+ Wide range of subtypes and some are normal gut commensals, ‘+ Some subtypes such as 0157 may produce lethal toxins resulting in haemolytic-uraemic syndrome ‘+ Enterotoxigenic E-Coli produces an enterotoxin (ST enterotoxin) that results in large volume fluid secretion into the gut lumen (Via CGMP activation) ‘+ Enteropathogenic E-Coli binds to intestinal cells and cause structural damage, this coupled with a moderate (or in case of enteroinvasive E-Coll significant) invasive component produces enteritis and large volume diarrhoea together with fever. + They are resistant to many antibiotics used to treat gram positive infections and acquire resistance rapidly and are recognised as producing beta lactamases Campylobacter jejuni + Curved, gram negative, non sporulating bacteria ‘+ One of the commonest causes of diarrhoea worldwide * Produces enteritis which is often diffuse and blood may be passed ‘+ Remains a differential for right iliac fossa pain with diarrhoea * Self limiting infection so antibiotics are not usually advised. However, the quinolones are often rapidly effective. Helicobacter pylori * Gram negative, helix shaped rod, microaerophillic * Produces hydrogenase that can derive energy from hydrogen released by intestinal bacteria + Flagellated and mobile * Those carrying the cag A gene may cause ulcers * It secretes urease that breaks down gastric urea> Carbon dioxide and ammonia> ammonium>bicarbonate (simplified!) The bicarbonate can neutralise the gastric acid. * Usually colonises the gastric antrum and irritates resulting in increased gastrin release and higher levels of gastric acid. These patients will develop duodenal ulcers. In those with more diffuse H-Pylorl infection gastric acid levels are lower and ulcers develop by local tissue damage from H-Pylor these patients get gastric ulcers. * Diagnosis may be made by serology (approx. 75% sensitive). Biopsy urease test during endoscopy probably the most sensitive. * Inpatients who are colonised 10-20% risk of peptic ulcer, 1-2% risk gastric cancer, <1% risk MALT lymphoma. Bie &- ii