Download - Grand Round Juhaina
Dr. Juhaina Al-Moosawi
Mentor :
Dr. Salma Al-Mauwali
Introduction :
Soft tissue infection :
A group of disease that involve the skin
, S/C , fascia or muscle .
Localized / involve a large portion .
Harmless if treated / life threatening
even when appropriately treated .
Classification :
• Localized/ superfecial infections
Cellulitis
Abscess
Impetigo
• Lethal infections
Toxic shock syndrome
Necrotizing fasciitis
Myonecrosis
Superficial
Deep
Cellulitis :
A soft tissue infection of the
skin & S/C .
Risk Factors :
• H/O trauma
• Skin injury .
• Underlying disease
(diabetes , impaired lymphatic drainage )
Clinical Feature :
• Pain
• Tenderness
• Erythema
• Swelling of the involved area
• Local warmth
Causes :
• Streptococcus pyogenes .
• Staphylococcus aureus.
Diagnosis :
• Clinical manifestations .
• Fever is uncommon .
• No workup in the following criteria:
Small area of involvement
Minimal pain
No systemic signs of illness
(fever, dehydration, altered mental status, tachypnea, tachycardia, hypotension) .
No risk factors for serious illness .
workup in serious cases :
• CBC
• U&E
• Blood cultures
• Aspiration of the wound
+ ve collection .
Imaging Studies :
• Plain XR unnecessary in
uncomplicated cases.
• Soft tissue XR or U/S :
purulent material or foreing body.
U/S guided aspiration of pus :
shorten hospital stay .
Antibiotic
AnalgesiaWarm packs
Elevation
Immobilization
Management
Disposition :
Cellulitis
In patientOut patient
Localized
No fever
Oral antibiotic
F/U 24-48 h
Increase erythematus area
Fever
Systemic symptoms
Systemic toxicity
Sever infection :
Hand , feet ,head ,
Neck , perineum .
Worsen cellulitis
48-72 h .
Immunocompramised
Paranteral antibiotic
Oral Therapy of Superficial Soft Tissue infection :
Agent Dose
Group A Streptococcus
Penicillin V ( phenoxymethylpenicillin)
First generation cephalosporin
Erythromycin
Azithromycin
Clarithromycin
Staphylococcus aureus ( not MRSA )
Dicloxacillin
generation cephalosporin
First
Cloxacillin
Erythromycin ( variable effectiveness )
Azithromycin
250 -500 mg qid
250 -500 mg qid
250 -500 mg qid
500 mg x 1 dose
Then 250 mg qd x 4
500 mg bid
125 -500 mg qid
250 - 500 mg qid
250 – 500 mg qid
250 – 500 mg qid
Then 250 mg qd x4
500 mg x 1 dose
Agent Dose
Clarithromycin
Clindamycin
Amoxicillin / clavulanate
Ciprofloxacin
Haemophilus influenzae
Amoxicillin / clavulanate
Cefactor
Trimethoprin (TMP)/sulfamethazone
(SMX)
Azithromycin
Clarithromycin
500 mg bid
150 -450 mg qid
875/125 mg bid
Or 500/125 mg tid
500 mg bid
250-500 mg tid
250-500 mg tid
160 mg TMP/800 mg
smx bid
500 mg x 1 dose
Then 250 mg qdx4
500 mg bid
Emergency Department Protocol for
the Management of Cellulitis , Nova
Scotia, Canad
Cellulitis :
Acute spreading inflammation
involving the soft tissue,
excluding muscle, characterized
by recent onset soft-tissue
erythema, warmth, swelling &
tenderness, considered to be of
infective origin, and acquired in
the community.
Department of Emergncy Medcine * and Pharmacy ^ Dalhousie University Halifax,
Nova Scotia, Canad
Journal of Emergency Primary Health Care (JEPHC)
• Excluded infected surgical wounds
or previously treated (< 3 months)
deep diabetic infections.
Cellulitis Grading scale :Grade Clinical features
I Symptoms/signs restricted to superficial swelling, erythema, warmth, mild
lymphadenopathy, & mild pain; absence of systemic symptoms in patients
without risk factors for poor outcome .
II dominant systemic signs – fever, chills lymphangitis &/or rapidly advancing
edge.
mild cellulitis (as defined in grade I) in high-risk, non-neutropenic, splenic
patients.
III severe facial, perineal or extensive skin involvement (i.e. if any dimension of
the area of skin involved is greater than the distance between the patient’s
median wrist and the point of the elbow).
failure to respond to >48 hrs of adequate oral Rx,
a history of episodes of cellulitis requiring prolonged intravenous therapy.
IV deep perineal, orbital, joint, or deep hand involvement.
cellulitis in neutropenic or asplenic patients.
suspicion of necrotizing, deep-seated infection or severe sepsis .
Infected bite
Diagnosis
of
Cellulitis1
Suspicion of
Abscess ? Appropriate
surgical
management.
Avoid antibiotics
unless surrounding
area of cellulitis.
Use the same grading
system for disposition, but
use Table I for antibiotic
choice.
Consider the possibility of
necrotizing infection ? Yes
NO
Grade IVGrade III Grade I Grade II
Cellulitis algorithm
NO
Grade I Grade II Grade IVGrade III
Immediately give
Clindamycin 900mg IV
and Ceftriaxone 2g IV
and IMMEDIATE
REFERRAL
IMMEDIATE
CONSULTS:
I.D. for all patients
plus:
Necrotizing
infection– surgery,
Deep hand
infection– Plastic
Surg.
Orbital cellulitis–
Opthalmology.5
Candidate for
home IV therapy4
NOYes
Cefazolin or
Cloxacillin
1-2g IV2,3
Probenecid 2g
po & Cefazolin
1-2g IV2,3
Refer for
admission
Closely supervised
home therapy.
Probenecid 2g po &
Cefazolin 1g IV q24
hrs. Change to P.O.
regimen as for Grade I,
if Grade I features
obtained for > 24 hrs.
Reassessment by FP
in 5 days.
Initial dose of Probenecid
2g po & Cefazolin 1-2g 2,3
Cephalexin 500 mg
QID po x 7 days.
or, Cloxacillin 500mg
QID po x 7 days
or, Azithromycin
500 mg po followed by
250 mg/day x 4 days.
Family doctor
and reliable
patient/family
NOYes
Return to ED
in 24-36h if
no
improvement
Follow-
up with
FP in
24-36h
Cephalexin 500
mg QID po x 7
days or,
Cloxacillin 500mg
QID po x 7 days
or, Azithromycin
500 mg po
followed by 250
mg/day x 4 days.
Family doctor
and reliable
patient/family
NOYes
Return
to ED in
36-48h if
no
improve
ment
Follo
w-up
with
FP in
48-
72h
Yes
probenecid
• Inhibit renal tubular
reabsorption of uric acid which
lower serum uric acid levels.
• It is recommended for patients
with gout.
• Increase & prolong the serum
level of the antibiotic.
Studies suggest that intravenous cefazolin 2
g and oral probenecid 2 g daily is an
effective regimen in the treatment of SSTI.
The Annals of Pharmacotherapy , 23 January 2004
Toxic shock syndrome
(TSS)
A shock syndrome caused by the
inflammatory response to toxins produced
by various bacteria .
Types of Toxic Shock
Syndrome
• Staphylococcus bacteria
(TSS).
• Group A Streptococcus bacteria
(STSS)
Epidemiology :
• Discovered in 1978 in 7 children aged 8-17 years who had
shock from Staphylococcus aureus .
• The peak incidence of TSS occurred in 1980 associated with
increased vaginal tampons use in menstruating women
~ 2.4 – 16 cases / 100,000 population .
• CDC reported 200 cases / year from 1994 – 2001 with a steady
increase in strep TSS & decrease in incidence of staph TSS since highly absorbent tampons were withdrawn from the market .
• Strept TSS was 1st described in 1987 when reported 2 cases of
shock due to isolated Step.Pyogenes .
• TSS remains as highly fatal disease with mortality rate 30%-70%.
Principles of disease
Staph . aureus Strep . pyrogenic
toxin
( TSST-1)
entertoxine
B
SPEA SPEB
exotoxin
BloodMononuclear
cells
IL TNF
cytokines
System
PATHOPHYSIOLOGY TSS:
3 phases:
1. Growth and multiplication of the
bacteria.
2. Production of the toxin.
3. Activation of the immune system.
PHASE 1
Menstrual blood enhances
the growth of S.aureus
by providing a growth
medium for the micro-
organism.
The tampons contain
fibres that inhibit the
lactobacilli & diminish
their ability to limit the
growth of S.aureus.
PHASE 2 ; TOXIN PRODUCTION
1. High protein levels
2. Neutral pH
3. High oxygen levels
• Menstrual blood increases the protein levels and provides a neutral pH which provides excellent conditions for toxin production.
• Tampons helps in introducing oxygen into the vagina also increasing toxin production.
• Tampons cause microtrauma and increase the risk of the exposure of the toxins to the blood..
Phase 3
superantigen toxin
MHC II + T cell
polyclonal T cell activation.
• cytokine storm
• TNF, (IL)
www.AMDTelemedicine.com
TSS Criteria for diagnosis
Fever of 38.9 c ( 102 F) or higher .
Rash ( diffuse macular erythema )that resembles the rash of scarlet fever
Desquamation of skin 1-2 weeks after onset of disease .
Hypotension ( syst BP less than 90 mm Hg , orthostatic drop of 15 mm Hg
or more or orthostatic dysness or syncope ) .
Clinical or lab abnormalities in at least 3 organ system :
GI : Nausea , vomiting , diarrhea .
Muscular : myalgia , creatine phosphokinase x 2 times normal .
Mucous membrane : vaginal oropharyngeal , conjunctival hyperemia .
Renal : Blood urea , creat X 2 times normal level , pyuria greater than 5
cells / high power field .
Hepatic : bilirubin , serum transaminases x 2 normal level .
Hematologic : thrombocytopenia , less than 100,000/mm3 .
Neurologic : disorientation or altered consciousness without focal
findings
Reasonable evidance for the absence of other cause of illness .
Definition of Streptococcal Toxic
Shock Syndrom
Must meet criteria from both 1 & 2 below :
1. Isolation of group A Streptococcus from :
a. A normally sterile site such as blood or CSF is a definite cases.
b. A normally nonsteriel site such as sputum or skin lesion is a
probable case .
2. Hypotension & at least 2 of the following :
a. Renal impairment .
b. Coagulopathy .
c. Liver involvement .
d. Adult respitarory distress syndrome .
e. Generallized erythematous macular rash that may desquamate
f. Soft tissue necrosis .
Comparison of Staphylococcal &
Strptococcal TSS:Feature Staphylococcal Streptococcal
Age Primarily 15-35 yr 20-50 yr
Sex Greatest in woman Either
Sever pain Rare Common
Hypotension 100% 100%
Erythroderma rash Very common Less common
Renal failure Common Common
Bacteremia Low 60%
Tissue necrosis Rare Common
Predisposing facto Tampons ,paking , Cut , burns
,Bruises ,
Varicella ,
NSAID use ?
Thrombocytopenia Common Common
Mortality rate less 3% 30%-70%
Risk Factors for Toxic Shock
SyndromeUse of superabsorbent tampons .
Post operative wound infections .
Post partum period .
Nasal paking .
Common bacterial infection .
Infection with influanza A .
Infection with varicella .
Diabetes mellitus .
Human immunodeficiency virus infection .
Chronic cardiac disease .
Chronic pulmonary disease .
Nonsteroidal anti inflammatory use ( may mask symptoms rather than
be a risk factor )
Complication :
• ARDS .
• SHOCK .
• Gangrene .
• Disseminated
intravascular
coagulation
(DIC ).
• Renal failure
DXD :
• Rocky mountain spoted fever .
• Streptococcal scarlet fever .
• Staphylococcal scalded-skin syndrome .
• Kawasaki syndrome .
• Leptospirosis .
• Viral illnesses
Managment :
• Aggressive IV fluid resuscitation .
• O2
• Removal of source of bacteria .
• Early antibiotic :
Recommended in strept TSS
Clindamycine : 600-900 mg IV x8h
• Wound debridement .
• Hyperbaric oxygen therapy .
• Vasopressor .
• Immunoglobulin IV 400 mg/ Kg .
• Corticosteroids if pt suspected of having Adrenal insufficiency related to underlying disease or chronic steroid use .
Necrotizing fasciitis
Progressive, rapidly spreading,
inflammatory infection located in
the deep fascia, with secondary
necrosis of the s/c .
• 1989 toxic shock syndrome and strep A
necrotizing fasciitis reported.
• The overall morbidity and mortality is 70-
80%.
• Strep NF is frequently associated with
STSS .
• A retrospective study showed that upper extremity necrotizing fasciitis has a high mortality rate.
• In their review, about 35% of patients died.
• A state of altered consciousness and respiratory distress at initial presentation were found to be statistically significant factors for eventual mortality
emedicine.medscape.com Mar 25, 2009
Michael Maynor, MD, Clinical Assistant Professor, Department of Hyperbaric/Emergency Medicine, Louisiana State University School
of Medicine
Types :
• Type I NF
Polymicrobial infection :
anaerobes , non-group A Strep.
• Type II NF
Monomicrobial infection :
group A beta hemolytic Strep
Clinical Features :
Stages of NF progression
• I (Early)
Erythematus /warmth
Tenderness
Edema
Fever
• II (Intermediate)
• Bullae formation
• Necrotic patches
• Oozing
• III (Late)
Crepitus
Skin anesthesia
Sever systemic reaction .
Risk factor :
• Surgical procedures
• ( intraperitoneal infections and
drainage perianal abscesses ).
• IM injections and IV infusions .
• Insect bites .
• Local ischemia and hypoxia
(e.g., diabetes).
• Alcoholics.
• NSAIDs .
Diagnosis :
• CBC
• U&E
• Ca
• Blood c/s : +ve in GAS
• Deep sample biopsy
• Local XR : presence of gas
• MRI differentiated between acute cellulitis from NF .
A risk score retrospectively devised in six
common laboratory parameters :
• CRP ≥150 mg/L (4 points) .
• WBC 15,000 to 25,000/microL (1 point) or >25,000/microL (2 points) .
• HGB 11.0 to 13.5 g/dL (1 point) or ≤11 g/dL (2 points) .
• Na < 135 meq/L (2 points) .
• Creatinine > 1.6 mg/dL (141 mmol/L) (2 points).
• Serum glucose > 180 mg/dL (10mmol/L) (1point).
Uptodate 2009
• A total score ≥6 should raise the suspicion
for necrotizing fasciitis ( 7-10%).
• score ≥8 was highly predictive (>75 %).
• The score is only useful when severe soft
tissue infection is strongly suspected.
Mangmnat :
• Surgical debridement .
• fluid resuscitation .
• Antibiotic therapy :
Type I :
• ampicillin + clindamycin / metronidazole.
Type II :
• Clindamycin + penicillin .
Uptodate 2009
Conclusion:
Rapid identification and rapid
treatment is essential for
recovery from aggressive
disease.