SOFT TISSUE INFECTIONSSOFT TISSUE INFECTIONSCH 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 important Early 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

Spore-forming Spore-forming ClostridialClostridial sp sp

Deepest necrotizing soft tissue infectionDeepest necrotizing soft tissue infection

Hallmarks are severe myonecrosis with gas production Hallmarks are severe myonecrosis with gas production and sepsisand sepsis

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

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

Ubiquitous organismsUbiquitous organisms

7 species, 7 species, C.perfringesC.perfringes 80-95% 80-95%

Gram +, spore forming anaerobic bacilli Gram +, 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(αα toxin) direct cardiodepressant, toxin) direct cardiodepressant, secondarily effects tissue breakdownsecondarily effects tissue breakdown

Mechanisms of infection are direct innoculation Mechanisms 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

““heaviness” of affected partheaviness” 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 gram-positive bacilli with or without GS: pleomorphic gram-positive bacilli with or without sporesspores

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) plus clindamycin (900 mg IV q8h), ceftriaxone and clindamycin (900 mg IV q8h), ceftriaxone and erythromycin alternativeserythromycin alternativesMixed infections require aminoglycosides, PCNase Mixed infections require aminoglycosides, PCNase resistant 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 to Presentation, eval and tx similar to Clostridial Clostridial spsp

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

Broad-spectrum coverage: unasyn, zosyn, timentin, Broad-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 A Rare form of invasive group A StreptococcusStreptococcus

No gas production, very virulentNo gas production, very virulent

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

Mortality 80 – 100 %Mortality 80 – 100 %

Necrotizing FasciitisNecrotizing FasciitisEpidemiologyEpidemiology

27/10,000 hospital admits27/10,000 hospital admitsNecrosis involving SQ and fascia (no muscle)Necrosis involving SQ and fascia (no muscle)““flesh-eating bacteria”flesh-eating bacteria”LE, UE, perineum, trunk, head, neck and buttocks in LE, UE, perineum, trunk, head, neck and buttocks in decreasing order of incidencedecreasing order of incidenceOverall mortality 25 – 50%Overall mortality 25 – 50%

Necrotizing FasciitisNecrotizing FasciitisPathophysiologyPathophysiology

Mixed-organism most commonMixed-organism 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

Necrotizing FasciitisNecrotizing FasciitisClinical 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 clearEarly, sensorium typically clear

Necrotizing FasciitisNecrotizing FasciitisDiagnosisDiagnosis

CBC with diff, chemistry with LFT’s, ABG, coags, serum CBC 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 “finger test”: local anesthesia, 2-cm incision into The “finger test”: local anesthesia, 2-cm incision into suspected area (deep fascial plane), lack of bleeding and suspected area (deep fascial plane), lack of bleeding and foul smelling cloudy fluid suggestive, place finger in 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

Necrotizing FasciitisNecrotizing FasciitisTreatmentTreatment

Aggressive fluid and resuscitationAggressive fluid and resuscitation

Avoidance of vasopressorsAvoidance of vasopressors

Antibiotics similar to nonclostridial myonecrosis: empiric Antibiotics similar to nonclostridial myonecrosis: empiric imipenem, meropemen or vancomycin, in PCN allergic imipenem, meropemen or vancomycin, in PCN allergic clindamycin and FQclindamycin and FQ

Surgical debridement mainstaySurgical debridement mainstay

HBOHBO

Necrotizing FasciitisNecrotizing FasciitisGroup A Streptococcus (GAS)Group A Streptococcus (GAS)

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 tissue

More 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 common most common

Pain and erythema at infection sitePain and erythema at infection site

Ecchymotic or frankly necrotic centerEcchymotic 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

Mostly Mostly staph staph or or strepstrep in adults, in adults, H. influenzaH. influenza in children in children

In patients with underlying disease, blood cultures and In patients with underlying disease, blood cultures and leukocytes indicatedleukocytes indicated

May require doppler to differentiate DVTMay require doppler to differentiate DVT

Cellulitis TreatmentCellulitis Treatment

Dicloxicillin, macrolide, azithromycin, clarithromycin, Dicloxicillin, macrolide, azithromycin, clarithromycin, amox-clavulanate for healthy outpatientamox-clavulanate 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 oxacillin

DM, ceftriaxone, imipenem or meropenemDM, ceftriaxone, imipenem or meropenem

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

Evidence of bacteremia or underlying disease, admission Evidence of bacteremia or underlying disease, admission to hospitalto hospital

ErysipelasErysipelas

Superficial cellulits involving lymphaticsSuperficial cellulits involving lymphaticsPrimarily GASPrimarily GASAbrupt onset, high fevers, chills, malaiseAbrupt onset, high fevers, chills, malaiseErythema with burning sensation, continues red, shiny Erythema with burning sensation, continues red, shiny hot plaque formshot plaque formsToxic striations and local lymphadenopathyToxic striations and local lymphadenopathyPenG in non DMPenG in non DMNafcillin, oxacillin, rocephin, augmentin in DMNafcillin, oxacillin, rocephin, augmentin in DMAdmission to hospitalAdmission to hospital

Cutaneous AbscessesCutaneous Abscesses

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

Scalp, trunk and extremity Scalp, trunk and extremity staphstaph

Oral and nasal mucosa Oral and nasal mucosa strepstrep

Intertriginous/perineal gram negative aerobes (Intertriginous/perineal gram negative aerobes (E.coliE.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 bodies Foreign bodies S. aureusS. aureus

Cat bites Cat bites Pasturella multicida, S. aureus, S. viridans, Pasturella multicida, S. aureus, S. viridans, Eikenella corrodensEikenella corrodens

Human bites Human bites P. multicida, Bacteroides fragilis P. multicida, Bacteroides fragilis andand Corynebacterium jeikeium, staph Corynebacterium jeikeium, staph and and 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 systemic

Immunocompromised demonstrating systemic infections Immunocompromised demonstrating systemic infections need blood culturesneed blood cultures

Foreign bodies need plain films +/- USForeign bodies need plain films +/- US

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 systemic Regional or field blocks, some may require systemic sedation or ORsedation or OR

Area prepped and draped in sterile fashionArea 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 TIDF/U 2-3 days, replace packing if neededF/U 2-3 days, replace packing if neededUse of antibiotics controversialUse of antibiotics controversialDM, alcoholics, immunocompromised, pt with systemic DM, alcoholics, immunocompromised, pt with systemic symptoms should receive antibioticssymptoms should receive antibioticsInvolving hands or face, more aggressiveInvolving hands or face, more aggressiveAntibiotic aimed at pathogen/locationAntibiotic aimed at pathogen/locationDuration 5-7 daysDuration 5-7 daysBe aware of bacterial endocarditisBe aware of bacterial endocarditis

Hidradenitis SuppurativaHidradenitis Suppurativa

Recurrent chronic infection of follicle within apocrine Recurrent 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 AA

Usually 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 with I & D, removing all hair and debris, packed with iodoform gauze, repacking 2 -3 daysiodoform gauze, repacking 2 -3 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 follicle

Tx: 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 by Mycotic infection cause by Sporothrix schenkiiSporothrix schenkii

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

Incubation period 3 weeks, 3 types of reactions, painless Incubation period 3 weeks, 3 types of reactions, painless nodule or papule, then SQ nodulesnodule or papule, then SQ nodules

Fungal culture, tissue biopsy diagnosticFungal culture, tissue biopsy diagnostic

Increased WBC, eosinophils, ESRIncreased WBC, eosinophils, ESR

Itraconazole 100 - 200mg QD for 3 – 6 months Itraconazole 100 - 200mg QD for 3 – 6 months

Gas Gangrene may present as:Gas Gangrene may present as:A. Pain out of proportion and heavinessA. Pain out of proportion and heavinessB. CrepitanceB. CrepitanceC. Bronze/brownish edema with malodorous dischargeC. Bronze/brownish edema with malodorous dischargeD. 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 resuscitationA. Aggressive fluids and resuscitationB. Empiric antibioticsB. Empiric antibioticsC. VasopressorsC. VasopressorsD. Surgical debridementD. Surgical debridementE. HBOE. HBO

3.3. T/F In Group A Strep Necrotizing Fasciitis, clindamycin has a T/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 usually T/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, 3 – 6 months1. E, 2. C, 3. T, 4. F staph, 5. F 3 weeks, 3 – 6 months