soft tissue infection

brief explanation

1. Cellulitis and soft tissue infection Presented by : Dr. Pritam Pandey Department of Surgery 1

2. Soft tissue infection Purulent (carbuncle , Furuncle , abscess ) Non purulent ( cellulitis , necrtizing infection , erysepelas ) 2

3. Cellulitis Non suppurative invasive inflamation subcutenous and fascial planes Causative agents Beta hemolytic streptococci Staphylococci C. perfringes Grams negative organisms 3

4. Common sites Lower extremities Face Scrotum 4

5. Clinical features Patient presents with an area of expanding erythema with other sign of inflamation Fever Tense shiny skin Toxic look Diabetic patient may present with dka No edge , no fluctuation ,n pus , no limit 5

6. Necrotising Fascitis Rapidly spreading destructive invasion of skin and soft tissue including deep fascia with relative sparing of muscles. Cause : type I - Anaerobes , gram negative, colliforms type II – Group A beta hemolytic streptococci 6

7. Risk Factor Diabetic Immunocompromised Patient on steroid therapy Obese Malnurished 7

8. site Lower extremities Genitalia Groin Lower abdomen 8

9. Clinical feature Sudden swelling and pain with edema discoloration necrosis and ulceration Toxemia Foul smelling discharge ( dish water like watery pus ) Rapid spread in short period (few hours) Feature of mods , sepsis 9

10. Erysepela Spreading inflamation of skin and subcutenous caused by streptococcal pygenes almost always assocated with cutenous lymphangitis with development of rose pink rash with cutenous lymphatic edema 10

11. Site Orbit , face , ear lobules Hands , scroutum Umbilicus in infants 11

12. Clinical feature Toxemia Rash ( blanchable ,fast spreading , with raised sharp margins ) Serous discharge Milians ear sign (skin of ear lobule adherent to subcutenous tissue ) 12

13. Non purulent infection Mild ( cellulitis / erypesela with no focus of purulence ) Moderate (typical cellulitis , erypesela with systemic signs of infection ) Severe ( patients who have failed oral antibiotics treatment , clinical sign of deep infection like bulla , sloughing, hypotension, immunocompromised patients , patient with systemic signs of inflamation ) 13

14. Non purulent infections Severe emergent surgical inspection and debridement rule out Necrotizing fascitis emperical antibiotics Vancomycin + pireracillin / tazobactam ) culture and sensitivity 14

15. Specific treatment Streptococcus pyogene / clotridial sps , penicillin + clindamycin Polymycrobial vancomycin + piparacillin / tazobactam 15

16. Moderate : iv antibiotics ( cefazolin , penicillin ceftriaxone , clindamycin ) Mild : oral antibiotics (penicillin v , cefalosporin , clindamycin ) 16

17. Elevation of limb Bandage applied with Mgso4 , glycerine 17

18. Purulent infection Furuncle Infection of hair follicle Caused by staph. Aureus Painful swelling discharging pus 18

19. Carbuncle infective gangrene of subcutenous tissue Causative agent :staph. Aureus Common in diabetic and immunocompromised Site : nape of neck , back , shoulder 19

20. Clinical feature Red hot coal like appearance Indurated surrounding Later on cribiform appearance and crateriform ulcer. 20

21. Abscess Localised collection of puss Fever , throbbing pain Signs of inflamation Fluctuating 21

22. Purulent infection Mild Moderate Severe Systemic signs counts (>12000/<400) RR (≥24/min) pulse (≥ 90/min) temp > 38 degree celcius 22

23. Mild (I &D ) Moderate and severe ( I & D and C/s) 23

24. Emperical Treatment Moderate TMP/SMX DOXYCYCLINE SEVERE VANCOMYCIN LINEZOLID DAPTOMYCIN TELEVANCIN CEFTAROLINE 24

25. Specific treatment Moderate MSSA : TMP/SMX MRSA : DICLOXACILLIN , CEFALEXIN SEVERE MSSA : NAFCILLIN , CEFAZOLIN , CLINAMYCIN MRSA : THOSE IN EMPERICAL 25

26. SURGICAL SITE INFECTION Superficial involve only the subcutaneous space, occur within 30 days of the surgery, documented with at least 1 of the following: purulent incisional drainage, positive culture of aseptically obtained fluid or tissue from the superficial wound, local signs and symptoms of pain or tenderness, swelling, and erythema after the incision is opened by the surgeon (unless culture negative) diagnosis of SSI by the attending surgeon or physician based on their experience and expert opinion. 26

27. Deep incisional infection involves the deeper soft tissue ( eg , fascia and muscle) occurs within 30 days of the operation or within 1 year if a prosthesis was inserted has the same findings as described for a superficial 27

28. organ/space SSI has the same time constraints and evidence for infection as a deep incisional SSI, involve any part of the anatomy (organs or spaces) other than the original surgical incision postoperative peritonitis, empyema , or joint space infection Any deep SSI that does not resolve in the expected manner following treatment should be investigated as a possible superficial manifestation of a deeper organ/space infection. 28

29. Local signs of pain, swelling, erythema , and purulent drainage provide the most reliable information in diagnosing an SSI. In morbidly obese patients or in those with deep, multilayer external signs of SSI may be delayed. While many patients with a SSI will develop fever, it usually does not occur immediately postoperatively, and in fact, most postoperative fevers are not associated with an SSI Flat, erythematous skin changes can occur around or near a surgical incision during the first week without swelling or wound drainage. 29

30. Most resolve without any treatment. The cause is unknown but may relate to tape sensitivity or other local tissue insult not involving bacteria. antibiotics begun immediately postoperatively or continued for long periods after the procedure do not prevent or cure this inflammation or infection Therefore, the suspicion of possible SSI does not justify use of antibiotics without a definitive diagnosis and the institution of other therapeutic measures such as opening the wound 30

31. From: Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the Infectious Diseases Society of America Clin Infect Dis. 2014;59(2):e10-e52. doi:10.1093/cid/ciu296 Clin Infect Dis | © The Author 2014. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected]. 31

32. Suture removal plus incision and drainage Adjunctive systemic antimicrobial therapy in conjunction with incision and drainage for surgical site infections associated with a significant systemic response ( such as erythema and induration extending >5 cm from the wound edge, temperature >38.5°C, heart rate >110 beats/minute, or white blood cell (WBC) count >12 000/µL (weak, low). 32

33. A brief course of systemic antimicrobial therapy is indicated in patients with surgical site infections following clean operations on the trunk, head and neck, or extremities that also have systemic signs of infection A first-generation cephalosporin or an antistaphylococcal penicillin for MSSA, or vancomycin , linezolid , daptomycin , telavancin , or ceftaroline where risk factors for MRSA are high (nasal colonization, prior MRSA infection, recent hospitalization, recent antibiotics 33

34. Agents active against gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole , are recommended for infections following operations on the axilla , gastrointestinal tract, perineum, or female genital tract 34

35. https://www.ahcmedia.com/articles/141208-skin-and-soft-tissue-infections https://academic.oup.com/cid/article-lookup/59/2/e10 https://www.accp.com/docs/bookstore/psap/2015B1.SampleChapter.pdf Bailey & Love's Short Practice of Surgery 26E (Williams, Bailey and Love's Short Practice of Surgery SRB MANUAL OF SURGERY 35

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