use these physicians to help me in managing particularly difficult infectious disease cases.
Now, I don't propose to give you a course in the use of antibiotics, but rather to give you some understanding of the types of microorganisms that are found, how they work, and some factors that influence whether patients develop infections and what influences their recovery or demise.
In general, bacteria are divided into two groups that are called Gram Positive and Gram Negative, depending whether they stain red or blue when prepared on a slide with a Gram's stain.
Bacteria produce substances called toxins, which are poisonous compounds, and these toxins act in the body to make you very sick. Living Gram positive bacteria often produce exotoxins, and dead bacteria produce endotoxins. These toxins may alter your body's ability to fight off or destroy bacteria or may cause bacteria which normally inhabit your body to become pathogenic and cause disease. Still other toxins may cause tissue to die and become liquefied, may cause blood vessels to clot off, or may cause swellings, bleeding, and shock.
What happens when you get an infection? We will call an early infection cellulitis, itis being a suffix that means “infection of” or infection of the cells. The old Latin words associated with infection are tumor (meaning swelling), dolor (meaning pain), calor (meaning heat), and rubor (meaning redness). If you take a moment, you can think of many English words which come from these basic Latin words, such as tumor, dolorous, rubious, and caloric. When a physician sees any of these signs, he must determine whether there is an infection and treat it appropriately. If the infection is allowed to progress, pus will form; an enclosed space with pus is called an abscess. The treatment of abscess today is much the same as it has been for thousands of years—open it and drain it.
When an infection spreads from one area, it may travel by way of a system called the lymphatic, which is just another type of vessel to carry waste from any area of the body, and this brings us to local collections of lymph in structures called lymph nodes. When you have a sore throat and it is red and painful, the infection may spread to the lymph nodes in your neck, and we say you have swollen glands.
When pus and bacteria get into the blood stream, this is called sepsis and can cause high fever and rapid and severe progression of illness leading to death if not controlled.
Well, what things lead to infection? From the point of view of the surgeon, he must be careful in his handling of the tissue, avoid injuring the blood supply to an area and do his utmost to avoid getting a buildup of blood called a hematoma in the operative site. In certain patients there may be an increased risk for infection, and these will include underlying diseases such as Diabetes Mellitus, Cancer, Anemia, Chronic diseases, certain medications such as steroids, and radiation therapy.
First, we should think of a situation where bacteria can get into the body. This is called contamination, such as may occur when you get a cut and the skin protection is breached, during an operation, or when someone suffers a knife or gunshot wound that injures the intestine and contaminates the surrounding body.
Several things will influence whether you develop a severe infection. First, how strong or dangerous are the bacteria which have entered the system? Next, we need to understand that the amount of bacteria is also important, as well as the length of time of the contamination. The method of contamination is important, i.e., was the patient stuck with a dirty nail, or splinter of wood that is still in the body? We will talk about different parts of the body in Part II of this book and will touch briefly on the types of infection that can occur there. The general health of the individual and the part involved will make a big difference. When there is good blood supply to an area, then the body's own defense system can get to the involved area and fight off infection. If the area has poor blood supply because of arteriosclerosis or hardening of the arteries, tissue damage, diabetes mellitus (which affects small blood vessels) or just general debility in very old or chronically ill people, then the bacteria may have an easier time growing and cause severe disease.
The physician will evaluate his patient for the presence of infection daily by looking for any of the four Latin word symptoms we have mentioned and, if they are present, he will perform certain laboratory tests to help him in the diagnosis and treatment. These may include chest xrays for signs of pneumonia, CAT scans, special radioactive injection studies called nuclear scans (such as Indium or Gallium), or a whole host of other radiological studies. In addition, he will do certain laboratory tests, which we will discuss in Chapter 25. Suffice it to say that a blood count, urinalysis, and cultures of any pus or wounds are very important in determining what type of antibiotic should be used.
Sometimes the organism causing a disease is not a bacteria but a fungus, such as in athlete's foot or “yeast” infections, or a virus as in AIDS, and these need different tests and different medicines for treatment.
This has been a lot of information to digest, but I do want to touch on some other points. First of all, some individuals are very allergic to certain drugs. They may have a bad reaction, which can be anything from a mild rash, to itching, breathing trouble, and sudden death. Physicians always ask a patient about any side effects from taking a medicine, and this is always highlighted on a medical chart. In the case of severe reactions, many patients have “Medic Alert” bracelets to inform anyone treating them of the danger.
When you have an infection, your doctor wants to treat you with the best drug with the least toxicity or side effects. One does not use a Cannon to kill a fly, and conversely, a peashooter will not kill an elephant. Physicians learn what types and amounts of drugs are best for each situation and, when it involves stronger drugs, which are much more dangerous to use but may be the last resort. They have to watch for hearing loss, kidney, liver and other problems. The field of infectious disease has become so complex that, when I have a patient with a ruptured appendicitis or ruptured colon, I often get consultation from the infectious disease specialist.
Just for your interest, I'm going to name some of the bacteria we see in a surgical practice. GramPositive organisms are Staphylococcus aureus, Pneumococcus, and Streptococcus. GramNegative organisms include Me-ningococcus, Escherichia Coli, Salmonella, Klebsiella, Haemophilus influ-enzae, Proteus, Clostridium, Pseudomonas, and Aerobacter. And these are only a few of the many, many organisms we find in human infections.
Some of the antibiotics used are Penicillin, Ampicillin, Flagyl, Erythromycin, Cephalosporin, Gentamicin, and Floxin, just to name a few. Take a look at the “Physician=s Desk Reference,” which lists all the drugs we commonly use, and you will find hundreds of antibiotics. You will also see a listing of the dosages and side effects, which can be very scary.
Treating infections can sometimes be very simple, but other times it may involve intravenous medications and, frequently, multiple combinations of medications.
Often a surgeon will give you what we call prophylactic antibiotics in anticipation of contamination or possible infection to prevent or lessen the impact of the bacterial contamination. Examples are gall bladder and intestinal surgery and certain orthopedic procedures.
This has been an overview of infection and antibiotics, and I hope it helps you to understand some of the problems that a physician will encounter in dealing with this situation.
Chapter 14
KNIVES, LASERS, AND CAUTERY
Knives, scimitars, dirks and cleavers
Daggers, shivs and snickersneevers,
Jackknives, rapiers, spears and krisses
Tomahawks, swords, stylets, cutlisses.
These all are very fine for fighting,
And if
