Clinical approach and principle of management of cellulitis and necrotising fascitis

RADIOLOGY PGT

1. Clinical approach and principles of management of cellulitis and necrotising fasciitis Presented By: Dr. Vipin Kumar JR-1 Department of General Surgery Moderator: Prof. Jitendra Kumar Kushwaha Professor Department of General Surgery

2. Definition An Acute, diffuse, spreading infection of the skin, involving the deeper layers of the skin and the subcutaneous tissue Periorbital cellulitis is a special form of celluliitis that usually occurs in children In this form of cellulitis, unilateral swelling and redness of eyelid and orbital area, as well as fever and malaise are usually present

3. Causes Staphylococcus Streptococcus Group A β H. Influenzae  Periorbital cellulitis) Pasteurella multocida Facial cellulitis in children <3 years old Hemophilus influenzae or Streptococcus pneumoniae

4. Predisposing Risk Factors Local trauma e.g., lacerations, insect bites, wounds, shaving) Skin infections such as impetigo, scabies, furuncle, tinea pedis Underlying skin ulcer Fragile skin Immunocompromised host Diabetes mellitus Inflammation Edema secondary to venosu insufficiency or lymphedema

5. Typical findings of cellulitis History Presence of predisposing risk factor Area increasingly red warm to touch, painful Area around skin lesion also tender but pain localized Edema Mild systemic symptoms- low- grade fever, chills, malaise, and headache may be present

6. Physical Assessment Local symptoms: Erythema and edema of area Warm to touch Possibly fluctuant  Tense, firm to palpation) May resemble peau d’ orange Advancing edge of lesion diffuse, not sharply demarcated Small amount of purulent discharge may be present Unilateral

7. Systemic indications: Increased temperature Increased pulse Lymphadenopathy of regional lymph nodes and/ or lymphangitis

8. Diagnostic Tests Swab any wound discharge for culture and sensitivity

9. Management and Interventions Do not underestimate cellulitis It can spread very quickly and may progress rapidly to necrotizing fasciitis It should be treated aggressively and monitored on an ongoing basis

10. Goals of Treatment for Mild cellulitis Resolve infection Identify formation of abscess Check tetanus prophylaxis

11. Non-Pharmacologic Interventions Apply warm of, if more comfortable, cool saline compresses to affected areas qid for 15 minutes Mark border of erythema with pen to monitor spread Elevate, rest and gently splint the affected limb

12. Pharmacologic interventions Pain management: Acetaminophen 10- 15 mg/kg per day PO q4-6 hours Do not exceed 75 mg/kg per 24 hours Oral antibiotics if no known MRSA or non-purulent cellulitis: Cephalexin 40 mg/kg per day PO divided qid for 7-10 days usually first choice due to taste) or cloxacillin 40 mg/kg per day po divided qid 7-10 days Patients with penicillin allergy: Erythromycin 40 mg/kg/day divided bit for 7-10 days Patients with known community acquired MRSA or purulent cellulitis: Trimethoprim- sulfamethoxazole 8-12mg/kg per day po bid for 7 days dosing is based on trimethoprim

13. Pregnant or Breastfeeding women Cephalexin, cloxacillin , erythromycin and acetaminophen may be used as listed above Trimethoprim- sulfamethoxazole is contraindicated

14. Necrotizing fasciitis Necrotizing fasciitis is commonly known as ‘Flesh eating disease’ or ‘Flesh Eating Bacteria Syndrome’ Rapidly progressive and destructive skin and soft tissue infection that involves subcutaneous tissue and fascia, spreads along fascial planes,skin may initially be spared

15. Necrotizing fasciitis classification:

16. Clinical course of necrotising fasciitis:

17. Clinical presentation:

18. Laboratory risk indicator for NF (LRINEC score ): Score of 5or below- low risk; 6–7 points- intermediate risk 8 points or more - high risk Fascial necrosis and loss of fascial integrity indicate a necrotizing infection. Muscle involvement and necrosis are indicative of an advanced stage.

19. Treatment approach: Initial management: Intensive hemodynamic support with intravenous fluid Definitive Management: Infected subcutaneous tissue is devitalized: Early and aggressive debridement of all necrotic tissues until the tissue start to bleed is pillar of NF management and may need more than one debridement, therefore, wound monitoring is mandatory and these patients on an average need 2 or more setting of debridement.

20. Surgical debridement of necrotic tissue within 24 hrs of presentation has significantly better outcome Antibiotic Therapy: Empirical broad spectrum antibiotic therapy: As common type of NF is polymicrobial , antibiotic regime targeting gram positive cocci , gram negative bacilli & anaerobes should be administered. Inj. Clindamycin +Inj. Piperacillin-Tazobactum + Inj. Metronidazole or 3rd Gen Cephalosporins . Monitoring for systemic toxicity (signs of systemic inflammatory response syndrome) as well as local signs and symptoms

21. Emerging treatment: Hyperbaric oxygen (HBO): Given at a pressure of 2 to 2.5 bar for 1 hour and thirty minutes, twice daily initially and then once daily Upto thirty sessions are required. Necrotic tissue and skin should be excised prior to HBO therapy. Use of HBOT is a controversial topic, as there are no large randomised control trials yet to establish its beneficial role

22. Thank You

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