Soft Tissue Infections 2

8/8/2019 Soft Tissue Infections 2

http://slidepdf.com/reader/full/soft-tissue-infections-2 1/40

SOFT TISSUE INFECTIONSSOFT TISSUE INFECTIONS

CH 152CH 152

Cathy Bulgrin DOCathy Bulgrin DO

Patty Dwyer DOPatty Dwyer DO



Necrotizing Soft Tissue InfectionsNecrotizing Soft Tissue Infections

Differentiated by primarily by depthDifferentiated by primarily by depth

Polymicrobial, mixed aerobic and anaerobicPolymicrobial, mixed aerobic and anaerobic

Early recognition and aggressive treatment importantEarly recognition and aggressive treatment important

due to rapid progression and high mortalitydue to rapid progression and high mortality



Gas Gangrene (Clostridium Myonecrosis)Gas Gangrene (Clostridium Myonecrosis)

Rapidly progressive and limb/life threateningRapidly progressive and limb/life threatening

SporeSpore--formingforming Clostridial Clostridial spsp

Deepest necrotizing soft tissue infectionDeepest necrotizing soft tissue infection

Hallmarks are severe myonecrosis with gas productionHallmarks are severe myonecrosis with gas productionand sepsisand sepsis



Gas Gangrene (Clostridial Myonecrosis)Gas Gangrene (Clostridial Myonecrosis)

EpidemiologyEpidemiology

1,000 cases per year in US1,000 cases per year in US

Ubiquitous organismsUbiquitous organisms

7 species,7 species, C.perfringesC.perfringes 8080--95%95%

Gram +, spore forming anaerobic bacilliGram +, spore forming anaerobic bacilli

Found in soil, GI and female GUFound in soil, GI and female GU



Gas Gangrene (Clostridial Myonecrosis)Gas Gangrene (Clostridial Myonecrosis)

PathophysiologyPathophysiology

Produce over ten exotoxinsProduce over ten exotoxins

Exotoxin(Exotoxin( toxin) direct cardiodepressant,toxin) direct cardiodepressant,

secondarily effects tissue breakdownsecondarily effects tissue breakdown

Mechanisms of infection are direct innoculationMechanisms of infection are direct innoculation

(open wound), hematogenous spread(open wound), hematogenous spread



Gas Gangrene (Clostidial Myonecrosis)Gas Gangrene (Clostidial Myonecrosis)Clinical FeaturesClinical Features

Incubation < 3 daysIncubation < 3 days

Pain out of proportion to physical findingsPain out of proportion to physical findings

³heaviness´ of affected part³heaviness´ of affected part

Brawny edema and crepitance (later findings)Brawny edema and crepitance (later findings)

Bronze/brownish with malodorous serosanguineous d/c,Bronze/brownish with malodorous serosanguineous d/c,

bullae may be presentbullae may be present

Low grade fever, tachycardiaLow grade fever, tachycardia

Confusion, irritability or sensorium changesConfusion, irritability or sensorium changes



Gas Gangrene (Clostidial Myonecrosis)Gas Gangrene (Clostidial Myonecrosis)Clinical Features ContClinical Features Cont

Labs: metabolic acidosis, leukocytosis, anemia,Labs: metabolic acidosis, leukocytosis, anemia,

thrombocytopenia, coagulopathy, myoglobinuria,thrombocytopenia, coagulopathy, myoglobinuria,

myoglobinemia, liver/kidney dysfunctionmyoglobinemia, liver/kidney dysfunction

GS: pleomorphic gramGS: pleomorphic gram--positive bacilli with or withoutpositive bacilli with or withoutsporesspores

Radiologic studies may demonstrate gasRadiologic studies may demonstrate gas





Gas Gangrene (Clostidial Myonecrosis)Gas Gangrene (Clostidial Myonecrosis)TreatmentTreatment

1)1) Resuscitation: crystalloid, plasma, packed cellsResuscitation: crystalloid, plasma, packed cells

1)1) Antibiotics: PCN G (24 m units IV divided) plus Antibiotics: PCN G (24 m units IV divided) plusclindamycin (900 mg IV q8h), ceftriaxone andclindamycin (900 mg IV q8h), ceftriaxone anderythromycin alternativeserythromycin alternatives

Mixed infections require aminoglycosides, PCNaseMixed infections require aminoglycosides, PCNaseresistant PCN¶s or vancomycin. Tetanus as indicated.resistant PCN¶s or vancomycin. Tetanus as indicated.

3)3) Surgery: debridement is mainstaySurgery: debridement is mainstay

4) Hyberbaric oxygen (HBO): after debridement4) Hyberbaric oxygen (HBO): after debridement



Gas Gangrene (Nonclostridial Myonecrosis)Gas Gangrene (Nonclostridial Myonecrosis)

Mixed infections involving aerobic and anaerobicMixed infections involving aerobic and anaerobic

Presentation, eval and tx similar toPresentation, eval and tx similar to Clostridial Clostridial spsp

Pain not as pronounced, delay in presentationPain not as pronounced, delay in presentation

BroadBroad--spectrum coverage: unasyn, zosyn, timentin,spectrum coverage: unasyn, zosyn, timentin,meropenem or imipenemmeropenem or imipenem

Vanc, FQ and clindamycin in PCN allergicVanc, FQ and clindamycin in PCN allergic

Early debridement and HBOEarly debridement and HBO



Streptococcal MyositisStreptococcal Myositis

Rare form of invasive group ARare form of invasive group A S treptococcusS treptococcus

No gas production, very virulentNo gas production, very virulent

High rate of bacteremia and subsequent TSSHigh rate of bacteremia and subsequent TSS

Mortality 80Mortality 80 ± ± 100 %100 %



Necrotizing FasciitisNecrotizing Fasciitis

EpidemiologyEpidemiology

27/10,000 hospital admits27/10,000 hospital admits

Necrosis involving SQ and fascia (no muscle)Necrosis involving SQ and fascia (no muscle)

³flesh³flesh--eating bacteria´eating bacteria´

LE, UE, perineum, trunk, head, neck and buttocks inLE, UE, perineum, trunk, head, neck and buttocks indecreasing order of incidencedecreasing order of incidence

Overall mortality 25Overall mortality 25 ± ± 50%50%




PathophysiologyPathophysiology

MixedMixed--organism most commonorganism most common

If single organism, typically group A strepIf single organism, typically group A strep

Symbiotic relationship between bacteriaSymbiotic relationship between bacteria

Insults such as IV injections, surgical incisions, abscess,Insults such as IV injections, surgical incisions, abscess,insect bites and ulcersinsect bites and ulcers

DM, PVD, smoking, IV drugs are risk factorsDM, PVD, smoking, IV drugs are risk factors




Clinical FeaturesClinical Features

Pain out of proportion to physical examPain out of proportion to physical exam

Skin erythematous and edematousSkin erythematous and edematous

Discoloration, vesicles, and crepitus lateDiscoloration, vesicles, and crepitus late

Low grade fever, tachycardia are commonLow grade fever, tachycardia are common

Early, sensorium typically clear Early, sensorium typically clear






DiagnosisDiagnosis

CBC with diff, chemistry with LFT¶s, ABG, coags, serumCBC with diff, chemistry with LFT¶s, ABG, coags, serum

lactate, blood cultures, tissue cultureslactate, blood cultures, tissue cultures

Tissue biopsy down to deep fascial planeTissue biopsy down to deep fascial plane

The ³finger test´: local anesthesia, 2The ³finger test´: local anesthesia, 2--cm incision intocm incision intosuspected area (deep fascial plane), lack of bleedingsuspected area (deep fascial plane), lack of bleeding

and foul smelling cloudy fluid suggestive, place finger inand foul smelling cloudy fluid suggestive, place finger in

incision, just superior to deep fascia and push forward, if incision, just superior to deep fascia and push forward, if

finger dissects ST away from fascia without difficultyfinger dissects ST away from fascia without difficulty




TreatmentTreatment

Aggressive fluid and resuscitation Aggressive fluid and resuscitation

Avoidance of vasopressors Avoidance of vasopressors

Antibiotics similar to nonclostridial myonecrosis: empiric Antibiotics similar to nonclostridial myonecrosis: empiric

imipenem, meropemen or vancomycin, in PCN allergicimipenem, meropemen or vancomycin, in PCN allergicclindamycin and FQclindamycin and FQ

Surgical debridement mainstaySurgical debridement mainstay

HBOHBO



Necrotizing FasciitisNecrotizing FasciitisGroup A Streptococcus (G AS)Group A Streptococcus (G AS)

Presentation, eval and treatment similar to polymicrobialPresentation, eval and treatment similar to polymicrobial

Concomitant varicella infection especially in children,Concomitant varicella infection especially in children,

NSAIDs increase riskNSAIDs increase risk

Usually no gas formation in soft tissueUsually no gas formation in soft tissueMore rapid progression to bacteremia and TSSMore rapid progression to bacteremia and TSS

Broad spectrum antibioticsBroad spectrum antibiotics

Clindamycin synergistic effect with PCNClindamycin synergistic effect with PCN



Necrotizing CellulitisNecrotizing Cellulitis

Limited to skin and SQ, polymicrobialLimited to skin and SQ, polymicrobial

C. perfringesC. perfringes most commonmost common

Pain and erythema at infection sitePain and erythema at infection site

Ecchymotic or frankly necrotic center Ecchymotic or frankly necrotic center Systemic symptoms may be mild or absentSystemic symptoms may be mild or absent

Debridement and broad spectrum antibioticsDebridement and broad spectrum antibiotics



CellulitisCellulitis

Pain, induration, warmth and erythemaPain, induration, warmth and erythema

MostlyMostly staphstaph or or strepstrep in adults,in adults, H. influenzaH. influenza in childrenin children

In patients with underlying disease, blood cultures andIn patients with underlying disease, blood cultures and

leukocytes indicatedleukocytes indicatedMay require doppler to differentiate DVTMay require doppler to differentiate DVT



Cellulitis TreatmentCellulitis Treatment

Dicloxicillin, macrolide, azithromycin, clarithromycin,Dicloxicillin, macrolide, azithromycin, clarithromycin,

amoxamox--clavulanate for healthy outpatientclavulanate for healthy outpatient

If head/neck, admission for IV recommendedIf head/neck, admission for IV recommended

IV meds include cefazolin, nafcillin, or oxacillinIV meds include cefazolin, nafcillin, or oxacillinDM, ceftriaxone, imipenem or meropenemDM, ceftriaxone, imipenem or meropenem

Ancef and probenacid, effecacious as rocephin daily Ancef and probenacid, effecacious as rocephin daily

Evidence of bacteremia or underlying disease,Evidence of bacteremia or underlying disease,

admission to hospitaladmission to hospital



ErysipelasErysipelas

Superficial cellulits involving lymphaticsSuperficial cellulits involving lymphatics

Primarily G ASPrimarily G AS

Abrupt onset, high fevers, chills, malaise Abrupt onset, high fevers, chills, malaise

Erythema with burning sensation, continues red, shinyErythema with burning sensation, continues red, shinyhot plaque formshot plaque forms

Toxic striations and local lymphadenopathyToxic striations and local lymphadenopathy

PenG in non DMPenG in non DM

Nafcillin, oxacillin, rocephin, augmentin in DMNafcillin, oxacillin, rocephin, augmentin in DM

Admission to hospital Admission to hospital





Cutaneous AbscessesCutaneous Abscesses

Tender, swollen, erythematous, fluctuant noduleTender, swollen, erythematous, fluctuant nodule

Scalp, trunk and extremityScalp, trunk and extremity staphstaph

Oral and nasal mucosaOral and nasal mucosa strepstrepIntertriginous/perineal gram negative aerobes (Intertriginous/perineal gram negative aerobes (E.coli E.coli ,, P.P.

mirabilismirabilis,, Klebsiella spKlebsiella sp))

Axilla Axilla P. mirabilisP. mirabilis

Perirectal/genital anaerobic and aerobic (Perirectal/genital anaerobic and aerobic (bacteroides spbacteroides sp))



Cutaneous Abscesses, ContCutaneous Abscesses, Cont

Foreign bodiesForeign bodies S . aureusS . aureus

Cat bitesCat bites Pasturella multicida, S . aureus, S . viridans,Pasturella multicida, S . aureus, S . viridans,

Eikenella corrodensEikenella corrodens

Human bitesHuman bites P. multicida, Bacteroides fragilisP. multicida, Bacteroides fragilis andandCorynebacterium jeikeium, staphCorynebacterium jeikeium, staph andand strepstrep

IV drugs mixed with anaerobic prevailingIV drugs mixed with anaerobic prevailing



Diagnosis of Cutaneous AbscessDiagnosis of Cutaneous Abscess

No need for further eval if simple, healthy ptNo need for further eval if simple, healthy pt

Fever, tachycardia suggests systemicFever, tachycardia suggests systemic

DM, alcoholism, immunocompromisedDM, alcoholism, immunocompromised

CBC and ESR to evaluate for systemicCBC and ESR to evaluate for systemicImmunocompromised demonstrating systemic infectionsImmunocompromised demonstrating systemic infections

need blood culturesneed blood cultures

Foreign bodies need plain films +/Foreign bodies need plain films +/-- USUS



Treatment of Cutaneous AbscessesTreatment of Cutaneous Abscesses

Consent obtained, complications explainedConsent obtained, complications explained

If pus, I & DIf pus, I & D

If no pus, warm compresses and antibioticsIf no pus, warm compresses and antibiotics

Regional or field blocks, some may require systemicRegional or field blocks, some may require systemicsedation or ORsedation or OR

Area prepped and draped in sterile fashion Area prepped and draped in sterile fashion

No. 11 or 15 scalpel, hemostats for loculated areas,No. 11 or 15 scalpel, hemostats for loculated areas,

irrigated and packed with gauze tapeirrigated and packed with gauze tape



Treatment of Cutaneous Abscesses, ContTreatment of Cutaneous Abscesses, Cont

Warm compresses and soaking TIDWarm compresses and soaking TID

F/U 2F/U 2--3 days, replace packing if needed3 days, replace packing if needed

Use of antibiotics controversialUse of antibiotics controversial

DM, alcoholics, immunocompromised, pt with systemicDM, alcoholics, immunocompromised, pt with systemicsymptoms should receive antibioticssymptoms should receive antibiotics

Involving hands or face, more aggressiveInvolving hands or face, more aggressive

Antibiotic aimed at pathogen/location Antibiotic aimed at pathogen/location

Duration 5Duration 5--7 days7 days

Be aware of bacterial endocarditisBe aware of bacterial endocarditis



Hidradenitis SuppurativaHidradenitis Suppurativa

Recurrent chronic infection of follicle within apocrineRecurrent chronic infection of follicle within apocrine

glandgland

Occur in axilla, groin and perianal regionsOccur in axilla, groin and perianal regions

Higher in women and AAHigher in women and AAUsually staph, can be strepUsually staph, can be strep

I & D, surgeon referral, antibiotics if areas of cellulitis or I & D, surgeon referral, antibiotics if areas of cellulitis or

systemic symptomssystemic symptoms



Infected Sebaceous CystInfected Sebaceous Cyst

Erythematous, tender nodule, often fluctuantErythematous, tender nodule, often fluctuant

I & DI & D

Capsule must be removed at follow up visitCapsule must be removed at follow up visit



Pilonidal AbscessPilonidal Abscess

Superior gluteal foldSuperior gluteal fold

Staph most commonStaph most common

I & D, removing all hair and debris, packed withI & D, removing all hair and debris, packed with

iodoform gauze, repacking 2iodoform gauze, repacking 2 --3 days3 days

Surgical referralSurgical referral



Staphylococcal Soft Tissue AbscessesStaphylococcal Soft Tissue Abscesses

Folliculitis = inflammation of hair follicleFolliculitis = inflammation of hair follicle

Tx: warm soaksTx: warm soaks

Furuncle (boil) = abscess of hair follicleFuruncle (boil) = abscess of hair follicleTx: warm compresses to promote drainageTx: warm compresses to promote drainage

Carbuncle = coalescing furuncles, large infectionCarbuncle = coalescing furuncles, large infection

Tx: surgical excisionTx: surgical excision









SporotrichosisSporotrichosis

Mycotic infection cause byMycotic infection cause by S porothrix schenkii S porothrix schenkii

Commonly found on plants, vegetation and soilCommonly found on plants, vegetation and soil

Incubation period 3 weeks, 3 types of reactions, painlessIncubation period 3 weeks, 3 types of reactions, painless

nodule or papule, then SQ nodulesnodule or papule, then SQ nodulesFungal culture, tissue biopsy diagnosticFungal culture, tissue biopsy diagnostic

Increased WBC, eosinophils, ESRIncreased WBC, eosinophils, ESR

Itraconazole 100Itraconazole 100 -- 200mg QD for 3200mg QD for 3 ± ± 6 months6 months







Gas Gangrene may present as:Gas Gangrene may present as:

A. Pain out of proportion and heaviness A. Pain out of proportion and heaviness

B. CrepitanceB. Crepitance

C. Bronze/brownish edema with malodorous dischargeC. Bronze/brownish edema with malodorous discharge

D. ConfusionD. ConfusionE. All of the aboveE. All of the above

2.2. Treatment of necrotizing fasciitis includes all the following except:Treatment of necrotizing fasciitis includes all the following except:

A. Aggressive fluids and resuscitation A. Aggressive fluids and resuscitation

B. Empiric antibioticsB. Empiric antibioticsC. VasopressorsC. Vasopressors

D. Surgical debridementD. Surgical debridement

E. HBOE. HBO



3.3. T/F In Group A Strep Necrotizing Fasciitis, clindamycin has aT/F In Group A Strep Necrotizing Fasciitis, clindamycin has a

synergistic effect with PCNsynergistic effect with PCN

4.4. T/F Cutaneous abscess of scalp, trunk and extremity are usuallyT/F Cutaneous abscess of scalp, trunk and extremity are usually

Strep sp.Strep sp.

5.5. T/F Sporotrichosis incubation 3 days, treatment 3 weeksT/F Sporotrichosis incubation 3 days, treatment 3 weeks

1. E, 2. C, 3. T, 4. F staph, 5. F 3 weeks, 31. E, 2. C, 3. T, 4. F staph, 5. F 3 weeks, 3 ± ± 6 months6 months

Documents

Soft Tissue Infections 2