Deadly soft tissue infections

Dr. Faisal Al sawafi

Emergency Physician

Ibra Hospital

Case 1

• 70 year old male , known case of

diabetes, not HTN, present with history

of redness , pain over perineal area for

last 2 days..

• o/e

• Temp 39, pr 120, bp 100/60

• minimal tenderness on scrotum and penis

Objectives

• To be able to recognize soft tissue infections early

• To formalize an approch for dealing with patient of soft tissue infection

• Understand importance of MRSA infections in management of soft tissue infection.

• Able to differentiate which cases need admission versus discharge

Anatomy

importance

• Common

• Vague presentations and difficult

examinations.

• MRSA

MRSA

• global emerging

• cause severe, invasive infections

• Cause around 59% of purulent skin and

soft tissue infections in patient >18

years old.

• 75% of purulent skin abscess in children

Risk factors

• DM

• Hospitalization

• Admission in ICU

• Previous antibiotic use

• Endotracheal intubation with MV

• Nasogastric or gastrotomy tube

• Foleys catheter

• Immunosuppression or chronic illness

• Absence of “risk factors” does NOT

exclude MRSA

because

• About 50% have no risk factors

Diagnosis

• On clinical background

• Any skin or soft tissue infections or

sepsis

Treatment

Miller LG, et al. Clin Infect Dis.

Fridkin SK, et al. N Engl J Med.

Susceptibility

patterns are

dynamic & vary

geographically

Variable sensitivity

• Clindamycin (83-95%)

• Tetracycline (81-92%)

• Ciprofloxacin (15-79%)

• Erythromycin (6-44%)

Case 2

Ludwigs angina

• Cellulitis of submandibular and

subligual space

• 50 – 80% : bad dental hygiene

Why it is deadly

• Life threatining, rapid aggressive

• difficult airway management

• Mortality 5- 10%

• May spread to deep cervical fascia,

carotid sheath and retropharyngeal

space , cause mediastinitis

• Organism : fusobacterium,

bacteroides, anerobes, spirochetes

(0ral cavity anaerobes) may mixed

with staph and strep

Signs and symptoms

• Febrile, neck pain, odynophagia,

dysphagia, drooling, leaning forward.

• Tender, symmetrical swelling in

submandibular area.

• Cyanosis, tachypnea, stridor, agitation

Diagnosis

Treatment

• Airway

• Airway

• Airway

Antibiotics

• Pinicillins with clindamycin

• Ampicillin-sulbactam, metronidazole

and penicillin, imipenim-cilastatin,

piperacillin-tazobactem

• MRSA coverage

Steroids

• contraversial

Surgery

• Not responds to medical therapy

• Crepitus and purulent secretions

Case 3

• 12 year old girl present with left eyelid

swelling and red skin around eye for

last 2 days. She has also URTI

symptoms.

• o/e :

• Temp 38, eyelid redness , normal eye

exam. Normal visual acuity

Periorbital cellulitis

Orbital cellulitis

Orbital cellulitis

• Ocular emergency.

• Infection of tissue posterior to orbital

septum.

• Caused by : ethmoidal sinusitis ,

endophthalmitis, trauma, poor dental hygiene

Organism

• Staph aureus

• Strep. pneumoniae

• H.influena

Why it is deadly ?

• Orbital abscess

• Brain abscess

• osteomyelitis

• Meningitis

• Cavernous sinus thrombosis

signs

• Periorbital redness and swelling

• Decrease visual acuity

• Proptosis

• Chemosis

• Double vision

• Limitation of eye movement.

Diagnosis

• CT

Treatment

• Antibiotics (aerobea and anaerobes)

• 2nd or 3rd generation cephalosporin

• Ampicillin – sulbactem

• Carbapenems

• Fluroquinolones (penicillin allergy)

• Metronidazole or clindamycin for

anaeobes

Case 4

• 60 year old male, k/c/o DM on

treatment, present with left thigh pain,

redness and blisters for 2 days

• o/e

• temp 39.5, pr 110, bp 110/70

Necrotizing fasciitis

Why it is deadly

• Extensive soft tissue infection

• Systemic toxicity

• High morbidity

• Mortality is 25 – 35%

Risk factors

• Age

• DM

• Peripheral vascular disease

• Alcoholism

• Heart disease

• Renal and heart failure

• Cancer, hiv

Microbiology

• Type 1 polymicrobial :

• Type II monomicrobial :

(staphylococcus, streptococcus,

clostridim species and MRSA)

• Type III : vibrio vulnificus

Clinical features

• Pain out of proption on physical

examination

• Redness, tenderness

• Crepitus

• Fever

• tachycardia

Diagnosis: XRAY

US

CT ; sensitivity 80%

Treatment

• Early resussitation

• Packed RBC transfusion

• Empirical antibiotic (ampicillin

sulbactam, 3rd cephalo, carbapenem)

Surgical consult

Operative exploration

Fourniers gangrene

Clostridial myonecrosis

• Caused by : clostridim prifingens

• Deadly : limb and life threatinng

• Treatment : penicillin + clindamycin

Case 5

• 40 year old male with peripheral

vascular disease, present with redness

over left lower limb for 5 days with

fever and rigors

• o/e: temp 39, pr 105, bp 120/60

• Ill defined Erythema, swelling up to mid

leg

Why it is deadly

• Acute fast spread of infection

• Systemic toxicity

• Limb threatining

Risk factors

• Immunocompromized

• Peripheral vascular disease

• Lymphedema

• Skin breakdown

• venous insufficiency

Microbiology

• 80 % gram positive

• Beta-hemolytic streptococci

• Staph aureus (MRSA)

• Less common

• Haemophilus influenza

• Organisms from animal or human bites

Diagnosis

• Inflammatory markers

• Blood culture

• Needle aspiration

• Culture of pus, bullae

• US +- doppler

clinical

cobblestoning

• US finding of cellulitis

Treatment

• For outpatient: cephalexin or

clindamycin or tetracyclin

• Inpatient : vancomycin, clindamycin,

linezolid and daptomycin

MRSA coverage

• If

• purulent discharge

• Penetrating trauma

• Known MRSA colonization

• IV drug use

Toxic shock syndrome

• toxin-mediated bacterial skin

syndrome

Why deadly soft tissue infection

• Bacteremia is common with positive

blood cultures in about 60%.

• Serious multisystem complications are

common, including : DIC, RF, ARDS

Treatment

• Critical care resuscitation

• Removal of potential source

• Antibiotics including clindamycin and

vancomycin

• Surgical consultation

Summary

• Early recognition of soft tissue infection

• Do not forget MRSA coverage when

suspected

• Early antibiotic for devastating soft

tissue infections

• Early surgical consultation for

necrotizing faccitis

Thanks alot