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soft tissue infection
- 1. Cellulitis and softtissue 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 suppurativeinvasive inflamation subcutenous and fascial planes • Causative agents 1. Beta hemolytic streptococci 2. Staphylococci 3. C. perfringes 4. Grams negative organisms 3
- 4. Common sites • Lowerextremities • Face • Scrotum 4
- 5. Clinical features • Patientpresents 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 • Rapidlyspreading 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 • Suddenswelling 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 inflamationof 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 1.Streptococcus pyogene / clotridial sps, penicillin +clindamycin 2. Polymycrobial vancomycin +piparacillin/tazobactam 15
- 16. • Moderate :iv antibiotics (cefazolin, penicillin ceftriaxone , clindamycin ) • Mild : oral antibiotics (penicillin v , cefalosporin , clindamycin ) 16
- 17. • Elevation oflimb • Bandage applied with Mgso4 , glycerine 17
- 18. Purulent infection Furuncle • Infectionof hair follicle • Caused by staph. Aureus • Painful swelling discharging pus 18
- 19. Carbuncle • infective gangreneof subcutenous tissue • Causative agent :staph. Aureus • Common in diabetic and immunocompromised • Site : nape of neck , back , shoulder 19
- 20. Clinical feature • Redhot coal like appearance • Indurated surrounding • Later on cribiform appearance and crateriform ulcer. 20
- 21. Abscess Localised collection ofpuss • 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: (1) purulent incisional drainage, (2) positive culture of aseptically obtained fluid or tissue from the superficial wound, (3) local signs and symptoms of pain or tenderness, swelling, and erythema after the incision is opened by the surgeon (unless culture negative) (4) 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 • hasthe 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 signsof 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 resolvewithout 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 Guidelinesfor 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 removalplus 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 briefcourse 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 activeagainst 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.S ampleChapter.pdf • Bailey & Love's Short Practice of Surgery 26E (Williams, Bailey and Love's Short Practice of Surgery • SRB MANUAL OF SURGERY 35
- 36.
Editor's Notes
- #32 Table 1. Strength of Recommendations and Quality of the Evidence