Purulent materials

The primary goals of treatment are correction of the intraabdominal disease processes or injuries that have caused infection and drainage of collections of purulent material (abscess). A secondary objective is to resolve the infection without major organ system complications (e.g., pulmonary, hepatic, cardiovascular, or renal failure) or adverse drug effects. Ideally, the patient should be discharged from the hospital with full function for self-care and routine daily activities. 

Clinical specimens obtained for the recovery of dematiaceous fungi usually do not require extensive processing. If aspirated specimens contain a substantial amount of purulent material, this can be dissolved with N-acetyl-L-cysteine without sodium hydroxide. Tissue specimens and biopsy material should be homogenized in a tissue homogenizer after highly suspicious areas consisting of necrotic, purulent, or caseous material are selectively examined microscopically and inoculated onto isolation media. 

The goals of treatment are the correction of intraabdominal disease processes or injuries that have caused infection and the drainage of collections of purulent material (e.g., abscess). 

Because of the antibiotic resistance of many subspecies of Staphylococcus, it is recommended that culture and sensitivity studies of any purulent material be undertaken to maximize the chance for successful treatment of canaliculitis. Antibiosis should be directed at the specific causative organism isolated. Systemic penicillin is usually recommended in treating actinomyces, in addition to topical penicillin. 

Success in eradicating the infection also depends on removal of concretions and purulent material from the involved canaliculi. Actinomyces species are especially problematic in this regard, often forming casts within the canaliculus. These particles make it exceedingly difficult to treat cases of bacterial canaliculitis with topical medications alone in general, these dacryoliths must be removed before successful antibiotic treatment. In a few cases manual expression of the stones or casts is possible in others, canaliculotomy is required. In very resistant cases dacryocystorhinostomy may be necessary. 

Even when the pharmacokinetic parameters of a drug are such to suggest that it will reach the site of the infection, local factors can influence its antimicrobial activity. Aminoglycosides are ineffective in hyperosmolar, anaerobic acidic environments, such as the purulent environment of abscesses. Sulfonamides act by replacing para-aminobenzoic acid (PABA) in the folic acid synthetic pathway of bacteria and are ineffective in purulent material and necrotic tissue, which provide alternative sources of PABA. 

Severe COPD (chronic obstructive pulmonary disease) Initial 250 ml of 0.15 percent, which caused significant alveolar debridement and coughing up of copious amount of purulent material. Continued weekly infusions for six weeks, and by the end of the sixth treatment, the patient no longer was coughing. Comment Pulmonary function improved and the patient returned to working full-time. Maintained on treatment according to patient s "feel the need," which recurs approximately every four to six weeks. 

Crusted tops of lesions should be raised so that purulent material at the base of the lesion can be cultured. 

Primary peritonitis is treated with antimicrobials and rarely requires drainage. Secondary peritonitis requires surgical correction of the underlying pathology. The drainage of the purulent material is the critical component of management of an intraabdominal abscess. Without adequate drainage of the abscess, antimicrobial therapy and fluid resuscitation can be expected to fail. 

Fig 2 3 Implantable cardioverter-defibrillator (ICD)-pocket erosion. Part of the ICD header and can are visible. There is evidence of drainage of purulent material and blood from the ulceration without cellulitis. There is a slight bluish discoloring of tissues immediately caudal to the exposed portion of the ICD. Also note multiple scars (five) due to previous attempts to cure pocket infection without extraction of all the hardware, ICD, and leads... 

Stent insertion should be avoided or delayed in the presence of significant hemorrhage or urinary tract infection. The presence of a stent can become the nidus for infection and may be obstructed by purulent material or blood clot. In patients with a ureteral fistula and nondilated upper tracks, retrograde stent insertion is the preferred route because of the ease of insertion. 

Fig. 4.37a-c. Abscess around a bypass graft, a Long-axis and b short-axis 17-5 MHz US images over an occluded aorto-femoral bypass graft (arrows) in a 70-year-old diabetic patient with amputated lower leg and clinical signs of sepsis. Note the shrunken appearance of the graft surrounded by a fluid collection (asterisks), c Preoperative percutaneous drainage of the collection. The catheter (curved arrows) is seen inside the almost empty abscess (asterisks). As shown in the insert, aspiration resulted in purulent material... 

Fig. 12.63a,b. Infection after total hip replacement. Transverse oblique 2-4 MHz US images obtained over a the anterior and b the posterior aspect of the hip in a patient with a suspected infection of the hip prosthesis. In a, an irregular effusion (asterisk) containing echogenic material is found within the anterior recess of the pseudocapsule.de, acetabular component H, head N, neck of the prosthesis. In b, the posterior US image shows a para-articular fluid collection located posterior to the femur. A US-guided puncture was performed with sampling of purulent material... 

Drainage catheters of sufficient size (i.e. 8-14 F) to effectively drain purulent material can be placed using computed tomography, ultrasound or a combination ultrasound and fluoroscopic guidance (Fig. 27.3). Drainage catheters should be flushed on a daily basis... 

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