SGY-1.06 Surgical Infections PDF

MED 212 SURGERY 1 PINES CITY COLLEGES - DOCTOR OF MEDICINE MEDISINA 2024 Lecture/PPT | 1.06 SURGICAL INFECTIONS LECTURER: DR. BANNY BAY C. GENUINO DATE: FEBRUARY 11, 2022 2ND YEAR, 2ND SEMESTER Lecturer | Books & other references OVERVIEW HISTORICAL BACKGROUND DEFINITION OF TERMS PATHOGENESIS OF INF...

MED 212 SURGERY 1 PINES CITY COLLEGES - DOCTOR OF MEDICINE MEDISINA 2024 Lecture/PPT | 1.06 SURGICAL INFECTIONS LECTURER: DR. BANNY BAY C. GENUINO DATE: FEBRUARY 11, 2022 2ND YEAR, 2ND SEMESTER Lecturer | Books & other references OVERVIEW HISTORICAL BACKGROUND DEFINITION OF TERMS PATHOGENESIS OF INFECTION MICROBIOLOGY OF INFECTIOUS AGENTS PREVENTION TREATMENT INFECTIONS OF SIGNIFICANCE IN SURGICAL PATIENTS SIR ALEXANDER FLEMING HISTORICAL BACKGROUND 20th CENTU RY 1546 1665 1674 1847 1850 1854 1856 1862 1867 18761906 please see appendix for a larger image ANCIENT proposed miasma GREEKS theory begins early version of germ theory in De FRACASTORO Contagione et Contagiosis Morbis Observes cork cells HOOKE under a microscope VAN observes singleLEEUWENHOEK celled organisms demonstrates that hand washing reduces puerperal infections SEMMELWEIS saved lives with three words: wash your hands demonstrates that cholera bacteria SNOW were transmitted in contaminated drinking water discovers microbial fermentation while studying the causes of spoilage in beer and wine PASTEUR disproves spontaneous generation with swan-neck flask experiment begins using carbolic acid as LISTER disinfectant during surgery his workers determine KOCH causative agents for many bacterial infections WILLIAM OSLER DISCOVERY OF EFFECTIVE ANTIMICROBIALS Penicillin (Sir Alexander Fleming) prophylaxis against postoperative infection, to treat aggressive, lethal surgical infections NEW MICROBES WERE IDENTIFIED Microflora of the body that the surgeon encountered in the process of an operation were characterized UNDERSTANDING OF SIRS “Microflora of the body that the surgeon encountered in the process of an operation were characterized.” GERM THEORY OF DISEASE “Certain diseases are caused by specific germs or infections agents” Louis Pasteur Techniques of sterilization Pasteurization 1. The organism must always be present in every case of the disease, but not in healthy individuals. 2. The organism must be isolated from a diseased individual and grown in pure culture. 3. The pure culture must cause the same disease when inoculated into a healthy, susceptible individuals 4. The same pathogen must be isolated from the experimentally infected individuals. TRANSCRIBERS: ABAD | BATNAG | BOMOGAO | DACAWI | DECOYNA | GAMMOD | LABAWIG Page 1 of 17 MED 212 SURGERY 1 PINES CITY COLLEGES - DOCTOR OF MEDICINE 1.06 SURGICAL INFECTIONS LECTURER: DR. BANNY BAY C. GENUINO DATE: FEBRUARY 11, 2022 MEDISINA 2024 2ND YEAR, 2ND SEMESTER ANTISEPSIS HOST DEFENSES Lister's carbolic acid spray in action during an operation. Joseph Lister Pioneered principles of ANTISEPSIS surgery Reduced incidence of wound infections in THE APPENDICITIS OF KING EDWARD VII APPENDECTOMY: first intra-abdominal operation to treat infection via “source control” Pioneered by Charles McBurney DEFINITION OF TERMS INFECTION Invasion of the body by pathogenic microorganisms and the reaction of the host to organism and their toxins OVERVIEW blinking EYE tears lysozyme structural barrier sweat sebum lactic acid SKIN propionic acid lysozyme normal flora coughing/sneezing mucus RESPIRATORY ciliary action TRACT phagocytes lysozyme stomach acidity normal flora GI TRACT peristalsis antimicrobial compounds lavaging action of urine acidity of urine UROGENITAL lysozyme TRACT vaginal lactic acid normal flora ACTIONS THROUGH: mucus, ciliated epithelial cells, coughing, alveolar macrophages I. SKIN SURGICAL INFECTION An infection which developed before or as a complication of surgical treatment often requires surgical treatment PATHOGENESIS OF INFECTION Most extensive physical barrier Normal flora: gram-positive aerobes o Staphylococcus o Streptococcus o Corynebacterium o Propionibacterium Infra-umbilicus flora: gram-positive plus o Enterococcus faecalis and faecium o Escherichia coli, other Enterobacteriaceae o Candida albicans TRANSCRIBERS: ABAD | BATNAG | BOMOGAO | DACAWI | DECOYNA | GAMMOD | LABAWIG Page 2 of 17 MED 212 SURGERY 1 PINES CITY COLLEGES - DOCTOR OF MEDICINE 1.06 SURGICAL INFECTIONS MEDISINA 2024 LECTURER: DR. BANNY BAY C. GENUINO DATE: FEBRUARY 11, 2022 2ND YEAR, 2ND SEMESTER UROGENITAL, BILIARY, PANCREATIC DUCTAL, DISTAL RESPIRATORY TRACTS DO NOT possess resident microflora Altered by: - Disease: malignancy, inflammation, calculi - Foreign body: External source (foley, aspiration) II. GI TRACT STOMACH and SMALL BOWEL o highly acidic o Acidity affected by drugs and disease o Populations: 10^2 – 10^5 CFU/ml COLON o Most extensive host microflora o 10^11 – 10^12 CFU/ml in feces o Anaerobe: aerobe = 100:1 MICROORGANISMS FOUND IN THE GIT ANAEROBES Bacteroides fragilis Clostridium Bifidobacterium Eubacterium, Fusobacterium Lactobacillus Peptostreptococ cus AEROBES Escherichia coli Enterobacteriaceae Enterococcus faecalis and faecium FUNGUS candida INFECTION AND SYSTEMIC INFLAMMATORY RESPONSE SYNDROME (SIRS) CRITERIA FOR SIRS ALTERED MENTAL STATUS INFLAMMATORY VARIABLES HEMODYNAMIC VARIABLES ORGAN DYSFUNCTION VARIABLES TISSUE PERFUSION VARIABLES Plasma C-reactive protein: >2 s.d. above normal value Plasma procalcitonin: >20 s.d. above normal value Arterial hypotension o SBP 38.3°C Hypothermia: core temp 90bpm Tachypnea Significant edema or positive fluid balance (>20mL/kg over 24h) Hyperglycemia in the absence of diabetes Leukocytosis: WBC >12,000 Leukopenia: WBC 10% band forms PATHOGEN SOURCES ENDOGENOUS EXOGENOUS Patient flora Surgical ◊ Skin personnel ◊ Mucous ◊ soiled attire membranes ◊ breaks in ◊ GIT aseptic Seeding from a technique distant focus of ◊ inadequate infection hand hygiene OR environment & ventilation Tools, equipment, materials brought to the operative field COMMON PATHOGENS IN SURGICAL PATIENTS GRAM Staphylococcus aureus POSITIVE Staphylococcus AEROBIC epidermidis COCCI Streptococcus pyogenes Streptococcus pneumoniae Enterococcus faecium, E faecalis GRAM Escherichia coli NEGATIVE Haemophilus influenzae AEROBIC Klebsiella pneumoniae BACILI Proteus mirabilis Enterobacter cloacae, E aerogenes Serratia marcescens Acinetobacter calcoaceticus TRANSCRIBERS: ABAD | BATNAG | BOMOGAO | DACAWI | DECOYNA | GAMMOD | LABAWIG Page 3 of 17 PINES CITY COLLEGES - DOCTOR OF MEDICINE MED 212 SURGERY 1 1.06 SURGICAL INFECTIONS MEDISINA 2024 ANAEROBES GRAM-POS GRAM-NEG OTHER BACTERIA Citrobacter freundii Pseudomonas aeruginosa Stenotrophomonas maltophilia Clostridium difficile Clostridium perfringens, C tetani, C septicum Peptostreptococcus spp. FUNGI VIRUSES 2ND YEAR, 2ND SEMESTER LECTURER: DR. BANNY BAY C. GENUINO DATE: FEBRUARY 11, 2022 Bacteroides fragilis Fusobacterium spp. Mycobacterium aviumintracellulare Mycobacterium tuberculosis Nocardia asteroids Legionella pneumophila Listeria monocytogenes Aspergillus fumigatus, A niger, A terreus, A flavus Blastomyces dermatitidis Candida albicans Candida glabrata, C paropsilosis, C krusei Coccidiodes immitis Cryptococcus neoformans Histoplasma capsulatum Mucor/Rhizopus Cytomegalovirus Epstein-Barr virus Hepatitis A, B, C viruses Herpes simplex virus Human immunodeficiency virus Varicella zoster virus PATHOGENESIS OF STREPTOCOCCUS PYOGENES INFECTIONS VIRUSES FUNGI VIRUS majority surgical infection of immunocompromised pt GSCS: growth characteristics on specific media; sensitivity to a specific antibiotic SSI: aerobic commensals KOH, India ink, Giemsa; Look for branching and septation Polymicrobial infection: Candida albicans Diagnostics: Antibody tests, Polymerase chain reaction Nosocomial infxn: E. faecalis and faecium Aggressive soft tissue infection: Mucor, Rhizopus, Absidia Opportunistic infections: Aspergillus, Blastomyces, Cryptococcus Post-transplant patients: Adenovirus, EBV, CMV, VZV, HSV HCV, stick PREVENTION OF SURGICAL INFECTIONS I. PERI OPERATIVE PERIOD 1. Patient bathes or showers prior to surgery with either plain or antimicrobial soap 2. Use 2% mupirocin decolonization in known nasal carriers of Staphylococcus aureus in cardia and orthopaedic surgery (consider for other surgeries) 3. Do NOT remove patient hair, or if absolutely necessary, remove with a clipper, do not shave ▪ COMMON PATHOGEN IN SURGICAL PATIENTS COMMON TEST EXAMPLE BACTERIA Blood-borne pathogens: HBV, HIV Occupational infection rate (needle injury): 30:3:0.3 or 100:10:1 ▪ Preoperative Shaving/Hair Removal Method of hair removal ＊ ＊ ＊ Razor: 5.6% SSI rates Depilatory: 0.6% SSI rates No hair removal: 0.6% SSI rates ＊ ＊ ＊ Shaving immediately before: 3.1% SSI rates Shaving 24 hours before: 7.1% SSI rates Shaving >24 hours before: 20% SSI rates Timing of hair removal 4. Administer surgical antibiotic prophylaxis in the 120 minutes preceding surgical incision (depending on the type of operation and the half life of the antibiotic) Importance of timing of Surgical Antimicrobial Prophylaxis (AP) Prospective study of 2,847 elective clean and clean contaminated procedures ＊ Early AP (2-24 hrs before incision): 3.8% ＊ Postop AP (3-24 hrs after incision): 3.3% ＊ Periop AP (100 WBCs/mL ▪ multiple pathogens (polymicrobi al) ▪ Antibiotic 14-21 ▪ Removal indwelling devices: required recurrent infections ▪ Source control ▪ Antibiotic therapy (single or in combination) inflammation (infection of an intraabdominal organ) Tertiary “persistent” ▪ Standard therapy if secondary peritonitis fails Examples ▪ Intraabdominal abscess ▪ Postoperative peritonitis (leakage from anastomosis) Diagnosis ▪ Common in immunosuppre ssed ▪ >100 WBCs/mL ▪ multiple pathogens (mixed) ▪ mortality rate >50% Treatment for of ▪ Re-exploration and drainage ▪ Drained percutaneously ▪ Antibiotic therapy REMOVE DRAIN WHEN: Clinically improved Abscess cavity collapse Output less than 10 – 20 ml/day No evidence of ongoing source of contamination III. ORGAN SPECIFIC INFECTIONS Liver and Splenic abscess Characteristics Amoebic Liver abscess Secondary pancreatic infection ▪ 80% pyogenic ▪ 20% parasitic + fungal ▪ Organisms: - E. coli - K. pneumoniae - Bacteroides fragillis ▪ Super anterior aspect of right lobe near diaphragm ▪ Necrotic central portion ▪ Anchovy past ▪ Organisms: - E. histolytica ▪ Suspected in patients who: > Fail to resolve in 7– 10 days > Initially recover and develop sepsis 2–3 wks later TRANSCRIBERS: ABAD | BATNAG | BOMOGAO | DACAWI | DECOYNA | GAMMOD | LABAWIG Page 9 of 17 PINES CITY COLLEGES - DOCTOR OF MEDICINE MED 212 SURGERY 1 1.06 SURGICAL INFECTIONS LECTURER: DR. BANNY BAY C. GENUINO DATE: FEBRUARY 11, 2022 MEDISINA 2024 Liver and Splenic abscess Causes Amoebic Liver abscess ▪ Neglect appendicitis and diverticulitis ▪ manipulation of the biliary tract, 50% ▪ unknown ▪ Unmanaged Entamoeba histolytica GI infection ▪ U/S ▪ CT ▪ U/S ▪ CT ▪ Correction of underlying cause ▪ Antibiotics (gram negative + anaerobe) for 6-8 wks ▪ Percutaneous aspiration and surgical drainage may become necessary if medication fail ▪ Metronidazole for 7 – 10 days with imaging for F/U ▪ Aspiration rarely needed; reserved in patients with: - large abscess - fail medication - suspected superinfection - abscess at left lobe 2ND YEAR, 2ND SEMESTER Secondary pancreatic infection ▪ Infected pancreatic necrosis/ abscess Diagnosis ▪ CT and CTguided FNA(GSCS) ▪ CT: gas gangrene Treatment ▪ Stable patients: - antibiotics - minimally invasive drainage ▪ Unstable patients: - surgical debridement Computed tomographic scan of pyogenic liver abscesses. Multiple abscesses are seen in a patient after an episode of diverticulitis. Note the loculated large central abscess as well as the left lateral segmental abscess. IV. SKIN AND SOFT TISSUE INFECTIONS Classification Non-purulent lesion Purulent lesions Examples: Cellulitis Examples: Erysipelas Furuncles or boils Lymphangitis Treatment Antibiotics (gram- may drain positive skin spontaneously microflora) - require surgical incision and drainage - Antibiotics A. PURULENT LESIONS 1. ABSCESS  a swollen area within body tissue, containing an accumulation of pus ɤ PANCREATIC NECROSIS: MANAGEMENT ɤ 2. FOLLICULITIS  inflammation of the hair follicles TRANSCRIBERS: ABAD | BATNAG | BOMOGAO | DACAWI | DECOYNA | GAMMOD | LABAWIG Page 10 of 17 MED 212 SURGERY 1 PINES CITY COLLEGES - DOCTOR OF MEDICINE MEDISINA 2024 1.06 SURGICAL INFECTIONS LECTURER: DR. BANNY BAY C. GENUINO DATE: FEBRUARY 11, 2022 2ND YEAR, 2ND SEMESTER 3. FURUNCLES:  infected hair follicles with fluctuation V. NECROTIZING SOFT TISSUE INFECTIONS 4. CARBUNCLE  multiple furuncles 1. GAS GANGRENE 2. RAPIDLY SPREADING CELLULITIS 3. NECROTIZING FASCIITIS Extremely high mortality rate > 80-100% if delay treatment > 16-24% in rapid recognition B. NON- PURULENT LESIONS 1. ERYSIPELAS - RISK FACTORS: > Elderly > Immunosuppressed > Diabetes > Peripheral vascular disease SEPSIS WITH MINIMAL WOUND History: Pain out of proportion Examination: Greyish, turbid semi purulent material (dishwater pus) Skin changes: bronze color or brawny induration Blebs (hemorrhagic) Crepitus Investigation CBC, GSCS *Imaging in NOT recommended dur to delay intervention 2. CELLULITIS COMMON ORGANISMS Streptococcus pyogenes Pseudomonas aeruginosa Clostridium perfringens TREATMENT 1. Emergent aggressive and radical debridement 2. Immediate IV antibiotics 3. Septic shock resuscitation Antimicrobial agents directed against Gram (+), Gram (-) aerobes and anaerobes: VANCOMYCIN + CARBAPENEM High-dose aqueous PENICILLIN G (16,000,000 – 20,000,000 U/d) for Clostridial pathogens TRANSCRIBERS: ABAD | BATNAG | BOMOGAO | DACAWI | DECOYNA | GAMMOD | LABAWIG Page 11 of 17 MED 212 SURGERY 1 PINES CITY COLLEGES - DOCTOR OF MEDICINE MEDISINA 2024 1.06 SURGICAL INFECTIONS LECTURER: DR. BANNY BAY C. GENUINO DATE: FEBRUARY 11, 2022 2ND YEAR, 2ND SEMESTER NECROTIZING FASCIITIS WITH VACUUM DRESSING Dishwater pus ＊ Greyish, turbid semi purulent material SKIN CHANGES: ＊ Bronze color or brawny induration ＊ Blebs (hemorrhagic) ＊ Crepitus RESOLVED NECROTIZING SOFT TISSUE INFECTION: AFTER DEBRIDEMENT SKIN AND SOFT TISSUE INFECTION DIAGNOSIS AND MANAGEMENT NECROTIZING FACITIIS AFTER DEBRIDEMENT Please see appendix for a larger image VI. POSTOPERATIVE NOSOCOMIAL INFECTIONS 1 2 3 Catheter-Associated Urinary Tract Infection (CAUTI) Hospital-Acquired Pneumonia (HAP) Catheter-Related Bloodstream infection (CRBSI) or Central line-associated bloodstream infection (CLA-BSIs) TRANSCRIBERS: ABAD | BATNAG | BOMOGAO | DACAWI | DECOYNA | GAMMOD | LABAWIG Page 12 of 17 MED 212 SURGERY 1 PINES CITY COLLEGES - DOCTOR OF MEDICINE 1.06 SURGICAL INFECTIONS LECTURER: DR. BANNY BAY C. GENUINO DATE: FEBRUARY 11, 2022 MEDISINA 2024 CAUTI HAP 2ND YEAR, 2ND SEMESTER CRBSI or CLA-BSIS Diagnosis ▪ UA: +WBC, bacteria, leukocyte esterase ▪ Urine CS: symptomatic: 10^4 CFU/ml asymptomatic: 10^5 CFU/ml ▪ Purulent sputum ▪ Leukocytosis ▪ Fever ▪ New A/N CXR findings ▪ Pathogens are usually drug resistant ▪ Risk factors: - duration of central line - insertion or manipulation under emergency - nonsterile use of parenteral nutrition - multiple lumen catheter Prevention ▪ Remove catheter ASAP (usually 1-2 days postop) ▪ Wean ETT ASAP ▪ Early tracheostomy ▪ Full sterile technique ▪ Remove catheter ASAP Treatment ▪ Single antibiotic for 3-5 days (E. coli, K. pneumoniae) ▪ Commonly used: ofloxacin (200) 1 tab bid postop ▪ Remove catheter ▪ Vancomycin against MRSA ▪ S. epidermidis: antibiotics for 2-3 weeks For readings: https://www.cdc.gov/infectioncontrol/guideline s/cauti/index.html https://www.cdc.gov/infectioncontrol/pdf/guid elines/bsi-guidelines-H.pdf SURVIVING SEPSIS CAMPAIGN I. INITIAL EVALUATION & INFECTION ISSUES 3. ANTIBIOTIC THERAPY STARTED AS EARLY AS POSSIBLE Within the first hour after recognition of severe sepsis/septic shock DE-ESCALATION Broad spectrum antibiotic regimen (penetration into presumed source Reassess regimen daily ▪ Hypotension ▪ Elevated serum lactate ▪ 30 ml/kg IV crystalloid given in the 1st 3 hours RESUSCITATION GOAL ▪ CVP: 8-12 mmHg ▪ MAP of ≥65 mmHg ▪ UO of ≥0.5 mL/kg/h ▪ Mixed venous oxygen saturation of 65% 7–10 d for most infections Stop antibiotics for noninfectious issues 4. SOURCE CONTROL Establish anatomic site of infection implement source control measures immediately after initial resuscitation. Remove intravascular access devices if potentially infected. 5. INFECTION PREVENTION Selective oral and digestive decontamination. tract II. HEMODYNAMIC SUPPORT AND ADJUNCTIVE THERAPY 1. Fluid therapy 2. Vasopressor or Inotropic Therapy 1. INITIAL RESUSCITATION START RESUSCITATION DISCONTINUE ANTIBIOTIC TARGET RESUSCITATION ▪ Normalize lactate in patients with elevated lactate levels 3. Steroids 2. DIAGNOSIS GSCS (Gram stain & culture and sensitivity) - Prior to antibiotics - Do not delay antibiotic therapy Management Crystalloid ▪ Norepinephrine Target CVP: 8 to12 mm Hg Maintain MAP: ≥65 mm Hg is first-line choice ▪ Dopamine should NOT be used for “renal protection,” ▪ Phenylephrine is NOT recommended ▪ Dobutamine infusion (myocardial dysfunction) ▪ Arterial catheters for patients requiring vasopressors Consider intravenous hydrocortisone (dose ≤300 mg/d) for adult septic shock when hypotension responds poorly to fluids and vasopressors TRANSCRIBERS: ABAD | BATNAG | BOMOGAO | DACAWI | DECOYNA | GAMMOD | LABAWIG Page 13 of 17 MED 212 SURGERY 1 PINES CITY COLLEGES - DOCTOR OF MEDICINE 1.06 SURGICAL INFECTIONS MEDISINA 2024 LECTURER: DR. BANNY BAY C. GENUINO DATE: FEBRUARY 11, 2022 2ND YEAR, 2ND SEMESTER III. OTHER SUPPORTIVE THERAPY 1. BLOOD 2. MECHANICAL VENTILATION 3. SEDATION 4. GLUCOSE 5. PROPHYLAXIS Hemoglobin 4mmol/L TO BE COMPLETED WITHIN 6 HOURS: 5. Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation) to maintain a mean arterial pressure (MAP) i 65 mm Hg 6. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate >4 mmol/L (36 mg/dL): - Measure central venous pressure (CVP)* - Measure central venous oxygen saturation (Scvo2)* 7. Remeasure lactate if initial lactate was elevated* *Targets for quantitative resuscitation included in the guidelines are CVP of >8 mm Hg. Scvo2 of >70%. and normalization of lactate. CHECKPOINT: True/False 1. The germ theory of disease states that the organism must always be present in every case of the disease, but NOT in healthy individuals. 2. In the sequential organ failure assessment (SOFA) score, less than 2 points mean organ dysfunction. 3. During the peri operative period, it is absolutely necessary to remove the patient hair. 4. When risk of surgical infection is high, we do prophylaxis. Empiric therapy is done to reduce the number of microbes that enter the tissue or body cavity. 5. Penicillin allergy cross reacts with carbapenems and cephalosporin. 6. Surgical wound classification IV includes clean wound. 7. Deep incisional surgical site infections occur within 30 days of procedure or 1 year in the case of implants. 8. There is an 80-100% mortality rate if treatment is delayed in necrotizing soft tissue infections. 9. Antibiotic therapy is started within the first hour after recognition of severe sepsis/septic shock 10. Norepinephrine is infused in myocardial dysfunction as a hemodynamic support. 1T 2F 3F 4F 5T 6F 7T 8T 9T 10F TRANSCRIBERS: ABAD | BATNAG | BOMOGAO | DACAWI | DECOYNA | GAMMOD | LABAWIG Page 14 of 17 MED 212 SURGERY 1 PINES CITY COLLEGES - DOCTOR OF MEDICINE MEDISINA 2024 1.06 SURGICAL INFECTIONS LECTURER: DR. BANNY BAY C. GENUINOM FPSGS, FPCS, FPALES, FPAHBS, FACS DATE: FEBRUARY 11, 2022 2ND YEAR, 2ND SEMESTER Table 1. SIRS, qSOFA and new sepsis definition ANTIBIOTICS FOR SELECTED BACTERIA TRANSCRIBERS: ABAD | BATNAG | BOMOGAO | DACAWI | DECOYNA | GAMMOD | LABAWIG Page 15 of 17 MED 212 SURGERY 1 PINES CITY COLLEGES - DOCTOR OF MEDICINE 1.06 SURGICAL INFECTIONS MEDISINA 2024 LECTURER: DR. BANNY BAY C. GENUINOM FPSGS, FPCS, FPALES, FPAHBS, FACS DATE: FEBRUARY 11, 2022 2ND YEAR, 2ND SEMESTER PROPHYLACTIC USE OF ANTIBIOTICS ANTIFUNGAL AGENTS AND THEIR CHARACTERISTICS TRANSCRIBERS: ABAD | BATNAG | BOMOGAO | DACAWI | DECOYNA | GAMMOD | LABAWIG Page 16 of 17 MED 212 SURGERY 1 PINES CITY COLLEGES - DOCTOR OF MEDICINE MEDISINA 2024 1.06 SURGICAL INFECTIONS LECTURER: DR. BANNY BAY C. GENUINOM FPSGS, FPCS, FPALES, FPAHBS, FACS DATE: FEBRUARY 11, 2022 2ND YEAR, 2ND SEMESTER SKIN AND SOFT TISSUE INFECTION DIAGNOSIS AND MANAGEMENT TRANSCRIBERS: ABAD | BATNAG | BOMOGAO | DACAWI | DECOYNA | GAMMOD | LABAWIG Page 17 of 17