33 and 34 - Soft Tissue Infections Flashcards
1
Q
3 clinical patterns of infection
A
- Cellulitis
- Abscess
- Necrotizing fasciitis
2
Q
Cellulitis
A
o Skin and connective tissue infection and inflammation WITHOUT necrotic or purulent collections
o Cellulitis can start out as just inflammation then become as an abscess, but by definition, cellulitis is NOT purulent in nature
3
Q
Abscess
A
o Deep tissue infection WITH necrotic tissue and or purulent collections
o Involving tissue compartments, joints, tendon sheaths or deep spaces
4
Q
Necrotizing fasciitis
A
o Extremely rapid progression
o Life and limb threatening
NOTE: not really going to talk about this today
5
Q
Clinical signs and symptoms of cellulitis
A
o Erythema, edema
o Pain, fever, chills, malaise
o In diabetics with neuropathy, they will not have pain
6
Q
Clinical signs and symptoms of abscess
A
o Erythema, edema
o Fluctuance, purulence, necrosis (coming from the inside out)
o Treat with antibiotics
o Pain, fever, chills, malaise
7
Q
Clinical signs and symptoms of necrotizing fasciits
A
o Rapid wide spread necrosis
o Severe systemic symptoms (sepsis)
o CANNOT just treat with antibiotics, NEED to debride the necrosis
8
Q
Common organisms
A
- NOTE: you need to know what the most common organism is to start antibiotic therapy
o For cellulitis, there is no opening in the skin to culture, so we need to assume
9
Q
Common organisms in cellulitis
A
Strep. Group A, Staph. aureus
10
Q
Most common organism in abscess and post-operative infections
A
Staph. aureus
11
Q
Common organisms in a puncture wound
A
o Staph. aureus
o P. aeruginosa (osteomyelitis)
12
Q
MOST common organism in diabetic infections
A
o **Staph aureus ** (staph is almost ALWAYS present)
o Can be POLYMICROBIAL (challenging to treat)
13
Q
Community vs hospital acquired infections in terms of antibiotic resistance
A
- Community acquired infection has less antibiotic resistance
- Hospital acquired infection has more antibiotic resistance
- Healthy person is less likely to have an abx resistant infection (community acquired)
- If a NH patient comes in with an infection, we assume methicillin resistance
14
Q
Effect of long standing antibiotic therapy on antibiotic resistance
A
- Patients on long standing antibiotic therapy select out resistant organisms
- *****Prophylactic antibiotics should be limited in timing and spectrum (1 dose 30 min prior to surgery for staph) – Should NOT be doing 2 weeks of prophylactic antibiotics after surgery
- You can’t put everyone on abx just to be safe – that will cause more problems in abx resistance
15
Q
Polymicrobial infections
A
- Diabetic infections are in many cases poly-microbial
16
Q
MRSA
A
- MRSA is a major player in community and institutional acquired infections
17
Q
Clinical findings associated with soft tissue infection
A
- Fever
- Leukocytosis
- Lymphadenopathy
- Lymphangitis
- Bullae, purpura and other skin changes
- Increased ESR or C-reactive protein (Erythrocyte sedimentation rate and C-reactive protein measure overall inflammation in the body)
- Bacteremia (+ blood cultures)
18
Q
Fever
A
- > 100.5 degrees F
- Exogenous and endogenous pyrogens
- Individual variation and diurnal variation
19
Q
Fever patterns
A
o Continuous o Intermittent (spiking fever – common in abscess) o Remittent (parasitic – goes away, comes back few days later)
20
Q
Immunocompormised patient’s fever
A
- **NOTE ** If the patient is immunocompromised they may not mount a febrile reaction – A diabetic with renal failure will NOT have a high fever, even with a limb-threatening infection
21
Q
White blood count
A
WBC
o Leukocytosis > 12K
“With diff” - differential
o PMN percentage
o Left shift (immature WBCs, band cells, in blood stream)
o In immuno-compromised, you will not see a huge peak in WBC, but you will see slight elevation that will start to come down once abx therapy has been initiated
22
Q
Timing of sed rate and WBC increase in infection
A
o For sed rate, there is a lag time… You may see the sed rate continue to peak following WBC decline post-abx therapy, but the sed rate will start to come down after that
o Not as easy as just looking at the numbers – need to relate it to the patient
23
Q
Lymphatic involvement in soft tissue infection
A
- Inflammatory reaction in lymph channels
- Erythematous lymphatic streaking
- Palpable or painful lymph nodes
- Example: you can see red line coming down the leg, inguinal lymph nodes would likely be swollen, painful
24
Q
Blood cultures in soft tissue infection
A
- Identification of bacteremia
- Important to consider with profound systemic symptoms
- May be helpful to identify pathogen when local culture material is not available
- May be difficult to obtain positive culture with intermittent bacteremia of cellulitis and abscess
25
Sepsis
***********
Sepsis is a systemic response to a local infection
Example
o Foot ulcer (red hot swollen) and meet the criteria for SIRS = SEPSIS
26
Why is sepsis important to evaluate for?
***********
VERY IMPORTANT TO UNDERSTAND*******
| o Need to know this because it determines admittance to the hospital
27
Systemic Inflammatory Response Syndrome (SIRS)
*******
o Temp 100.5
o HR > 90
o Respirations > 20
o PaCO2 12K
Need 2-3 criteria
28
Types of sepsis (4)
KNOW THIS ***
Sepsis
o SIRS + Documented Infection
Severe Sepsis
o Sepsis + Organ dysfunction
o 25-30% Mortality
Septic Shock
o Sepsis + Acute persistent circulatory Failure
o 40-70% Mortality
Multi Organ Failure Syndrome
29
Organ dysfunction
- Altered mental status
- Edema
- Cardiac index > 3.5
- Acute oliguria
- Arterial hypoxemia
- High CR
- INR > 1.5
- Platelet count 1
30
What are the disease states that will contribute to a soft tissue infection?
****
* **THESE WILL ALTER THE PATIENT’S SYMPTOMS AND IMMUNE RESPONSE***
- Elderly
- Diabetes
- Transplant and HIV
- Steroid use
31
How does diabetes contribute?
o Immune-suppression
o Altered immune response (Fever, WBC, SIRS)
o PVD (Poor healing)
o Neuropathy (Reduced patient perception)
32
How does HIV and transplant contribute?
o Immune-suppression
33
How does steroid use contribute?
o Altered immune response
| o Blunted clinical symptoms
34
General treatment guidelines for infection
- Cellulitis can be treated with empiric antibiotics
- ****Incision and Drainage must be priority if abscess or necrosis are present - do not leave isolated pockets of necrosis or purulence***
- Delayed closure in most cases (open it and leave it open to drain)
- Culture deep tissues
Post I&D Antibiotics based on clinical scenario and patient health factors...
o Institutionalized patients may have MRSA
o Diabetic infections may be poly-microbial
35
Culture technique
- Superficial swipe is inaccurate for identification of deep pathogens
- Avoid skin contact to limit confusion of skin flora and pathogens
- ***Tissue is better than pus for culture material – DEEP TISSUE****
- Aerobic, anaerobic, fungal, acid fast
- Quantitative cultures
36
Antibiotic selection
Empiric choice first followed by culture directed drug of choice
***Best guess of the likely pathogens based on the patient medical history and clinical circumstances of the infection
37
Characteristics to look for in the drug of choice
o Highest specificity
o Lowest risk
o Lowest cost
38
Oral vs. IV antibiotics
o Oral drugs can have very good tissue penetration
| o Do not always need IV in otherwise healthy
39
Duration
This will vary based on the patient’s health status
40
IDSA guidelines for CELLULITIS
Very good guidelines to reference
Community Acquired:
o Strep. / Staph.
o Nafcillin – Cefazolin - Clindamycin
MRSA Suspected:
o TMP/SMZ - Clindamycin
Nosocomial (hospital-acquired)
o Vancomycin
41
IDSA guidelines for DIABETIC FOOT INFECTIONS
Mild (with no previous antibiotics)
o Dicloxacillin – Cephalexin – Clindamycin
o Nafcillin – Cefazolin - Clindamycin
Moderate (or with previous antibiotics)
o Ampicillin / Sulbactam – Clindamycin + Levaquin
42
Diabetic foot infections
- Poly-microbial (Aerobes, Anaerobes, G+, G-)
- Multi-system disease (Cardiac, Renal, PAOD, Neuropathy, Immunosuppression)
- Less amenable to out-patient care
- ***Patient may not exhibit symptoms**** (No pain – Neuropathy, low white count and fever – Immunosuppression)
43
IDSA guidelines for animal and human bites
- Non allergic (Ampicillin / Sulbactam)
- PCN allergy (Clindamycin + Levaquin)
- Most common organism in a dog bite = Pasturella
44
Paronychia - general
o Superficial nail fold infection
o Has characteristics of both cellulitis and abscess
o Well localized, usually not very deep or proximal infections
o In immunocompromised, it will be much more severe
45
Paronychia - clinical characteristics
Pain, erythema, purulence, granuloma, usually well localized, nail changes
46
Paronychia - treatment
o Incision & drainage is the mainstay
o Antibiotics rarely needed except for compromised host
o Culture only in special situations
o ***Staph., ***Strep., Candida (***= most common)
o We don’t usually even need abx
o NEED SURGICAL TREATMENT – ABX WILL NOT BE ENOUGH*********
47
Cellulitis - clinical characteristics
o NO PURULENCE
| o Erythema, warmth, pain, fever, chills, malaise, leucocytosis with left shift, contiguous source, no necrosis or pus
48
Cellulitis - treatment
o Empiric antibiotics, most commonly strep and staph
o Culture is usually not possible
o Admit to the hospital if the patient has profound symptoms, compromised host or failure of out-patient therapy
49
Criteria for hospital admission
- Profound clinical symptoms (Sepsis)
- One or more contributing disease states
- Antibiotics requiring inpatient monitoring
- Failure of out-patient therapy
- Suspicion of abscess requiring I&D
50
ISDA guidelines for admission
They revolve around SEPSIS
- Hypotension
- Increased creatinine
- Low bicarb
- Increased CPK
- Significant left shift
- C-reactive protein > 13
51
Monitoring recovery of soft tissue infections
```
We look at all of this to determine the next steps in treatment (debride again, send home, keep them in hospital, etc.)
o Clinical appearance
o Temperature
o Symptoms (pain, chills)
o WBC and differential
o ESR or C reactive protein
o Serial cultures???
```
52
Describe the controversy regarding serial cultures
- Some say 3 clean cultures before you can close the wound
| - MOST wounds will not have clean cultures ever, so need to look at more than this – whole patient approach
53
Deep infections
- Includes: abscess and puncture wound
54
Abscess - clinical characteristics
o Pain, cellulitis, lymphangitis, spiking fever, fluctuance, focal collection of necrotic material
55
Abscess - treatment
***********
o ***I&D/Culture – every hour we are not opening it up, more tissue is dying***
- THERE ARE TEST QUESTIONS ON THIS – Incision and drainage is the MOST IMPORTANT THING
o Empiric antibiotics
o Medical Evaluation
o Vascular and other Testing
o Directed antibiotics after cultures are available
o Open wound management
o Delayed closure or reconstruction – do NOT close this right away
56
What do you NEED to remember about an abscess?
ALWAYS INCISION AND DRAINAGE FIRST – EMERGENT*** (I&D) TEST QUESTION***
o “There will be test questions on this”
o Take culture at the same time
o If you start antibiotics before you take a culture, you have just altered the culture
57
Open wound management goals
Used for most infections after I&D to:
o Promote granulation
o Sequentially remove necrotic and infected tissue.
o Manage dead space
o Prevent subsequent sequestration
58
Basics of open wound management
- Continuously wet bandaging
- Serial debridement (have to be able to continue debriding the wound in the office or OR)
- Complete when granulation occurs and cellulitis and other signs resolved
59
CASE STUDY I
- 27 y/o healthy male just back from a camping trip, foot has been red for 3 days
- Severe pain, sweats and chills, tender in groin, oral temp 101.8, WBC 15.6K, ESR 32
- Draining for 1.5 days*** (tells you it is an abscess and not cellulitis), X-ray negative
- Diagnosis and plan: Abscess – I&D RIGHT NOW********
- Diagnosis is abscess in the foot with systemic sepsis because he has systemic symptoms as well
60
Criteria for hospital admission (recall from above)
- Abscess requiring I&D
- Profound clinical symptoms (sepsis)
- One or more contributing disease states
- Antibiotics requiring inpatient monitoring
- Failure of out-patient therapy
61
Plan for CASE STUDY I
- Plan: Hospital Admission, Emergent I&D, empiric antibiotics until cultures complete, medical optimization, saline bandages until the wound is clean and systemic symptoms have resolved, delayed closure when wound clean and granular
62
Delayed wound closure
- Primary closure vs. skin graft?
- Antibiotics after closure?
PLAN:
o Continue antibiotics for 5 days in otherwise healthy patient responding to treatment
o May need to consider longer course of abx if diabetic or if osteomyelitis
- 3 days later skin has recovered, wound is granular and very healthy looking
63
CASE STUDY II
- 70 y/o female with RA and DM, callus broke open 1 week ago and has been draining
- Painful in arch and ankle, feels weak
- N&V this AM, “thinks she has the flu”
- Oral temp 100.6 (can’t make a decision based on this due to immunocompromised)
- WBC 9.5K (can’t make a decision based on this due to immunocompromised)
- They think it is the flu and they are not associating it with the foot because it is not painful
- Arch compression yields drainage
- Plan: hospital admission, emergent I&D, empiric antibiotics until cultures complete, medical evaluation and optimization, vascular evaluation, directed antibiotics, saline bandages until wound is clean and systemic symptoms are resolved
64
CASE STUDY III
- 64 y/o male with NIDDM x 15 years
- Redness x 10 days, starting to drain, feels like he is getting the flu
- Oral temp 99.6, WBC 8.4K, blood sugar 270, non-palpable pulses
- Diagnosis is abscess with necrosis – NO vascular supply, so AFTER we halt the infection, we will get a vascular consult ASAP (I&D tonight, vascular consult tomorrow)
- Plan: hospital admission, emergent I&D, medical evaluation, empiric abx until cultures complete, vascular testing, advanced imaging, saline bandages until wound is clean and systemic symptoms have resolved
65
CASE STUDY IV
- 47 y/o IDDM with ulcer for 6 months, recent swelling in 2nd toe & forefoot
- No pain, feels fine, has had multiple past ulcers
- Temp 99.2, WBC 6.7K, ESR 55, x-ray shows extensive bone destruction, pulses palpable
- Most important factors in this patient is the multiple past ulcers, bone destruction, swelling in toe – Now we have an abscess in the toe
- Probably traveled up the tendon sheath – now you have a closed space infection, an abscess
- Plan: hospital admission, I&D, medical evaluation, empiric antibiotics, advanced imaging, directed abx, serial debridement and wound care
- Once infection has cleared, need to figure out how to close the wound – toe flap
- Eventually needed a transmetatarsal amputation, which removed the deforming forces to treat the ulcer as well as the infection – it was a functional amputation stub
66
CASE STUDY V
- 54 y/o female IDDM x 25 years, redness and swelling 5 days after twisting ankle
- No pain, feels fine, oral temp 98.5, WBC 8.9, HgA1c 9%, palpable pulses, swelling to the knee both extremities
- Ankle sprain or abscess? They made an incision and it was highly purulent, lots of drainage
67
CASE STUDY VI
- 62 y/o male with multiple episodes of gout, current episode x 7 days
- Severe pain, not responding to indomethacin, no response to oral abx, getting blisters on toes
- Fever and chills, oral temp 101.5, WBC 11K, tender in arch
- This is an abscess due to gout with necrosis of the toe, which is spreading proximally – the gout was traveling with the infection so there were crystals
- This is a deep space abscess in a single compartment of the plantarfoot
- Plan: admission, emergent I&D, medical evaluation, empiric abx, advanced imaging, serial debridement and wound care, reconstruction
- Gout – sodium urate tophi which “eats everything in its path” – there was no tendon capsule or bone left, just the sodium urate accumulation which can become acutely infected
68
CASE STUDY VII
- 75 y/o IDDM male with redness and L calf pain @ rest, acute onset 10 days ago, seen by two other doctors and treated with 2 courses of oral antibiotics
- Not responding to oral antibiotics and colchicine, uric acid 4.0, no open lesions, oral temp 99.0, WBC 5.0K, pulses not palpable, extensive heart disease history
- Diagnosis: PAD – occlusive vascular disease, determined this by testing for dependent rubor and elevation pallor
69
CASE STUDY VIII
- 67 y/o female admitted for cellulitis not responding to broad spectrum antibiotics
- Leg pain, temp 98.6, WBC 8.0, ESR 12, history of DVT
- Diagnosis: venous stasis – elevation makes it better, not the antibiotics
70
Puncture wound - general concepts
- Must determine the specific circumstances of trauma – environment, object, force of injury, timing of presentation, retained foreign body
- Get a detailed PMHx
- Initiate immediate treatment
- A lot of the same concepts as abscesses
71
Puncture wound treatment
- *****The aggressiveness of treatment is based on the zone of involvement
- *****I&D is the cornerstone of treatment
- Antibiotics are carefully considered
- Timing is extremely important
- Suspect Pseudomonas in osteomyelitis
- Always get X-ray
72
Puncture zones and risk associated
- Zone 1 - High risk***
- Zone 2 - Low risk (Zone 2 is a low risk because there is a lot of distance to the bone, muscle, tendon, etc.)
- Zone 3 - Mod risk
73
Clinical characteristics of puncture wounds
- History of trauma, pain
- Physical exam does not always tell the whole story
- Remember diabetics may have no symptoms or not be aware of trauma
- Should be treated aggressively before signs of cellulitis or abscess begin
- Everything is the same – don’t need to belabor this
- Depends on the environment of the injury***
- Depends on zone ***
74
Zone 1 puncture wounds
- Aggressive I&D and lavage in all cases, open management is necessary
- Antibiotics not mandatory unless high risk environment, compromised host, definite bone contact or fracture
- All injuries with bone penetration are treated with aggressive I&D
- Example: Puncture wound on the bottom with infection on the top – we know there is abscess because it has travelled to the joint – only way it can get to the top of the foot
75
Zone 2 and 3 puncture wounds
Local I&D, antibiotics carefully considered
Open management if:
o Deep penetration / Bone contact
o Contaminated environment
o Compromised host
```
Zone 2 in a Healthy Patient
o Local anesthesia
o Mini I&D
o Extensive lavage
o open
```
Zone 2 in a Patient with Systemic Complication
o Aggressive I&D
o Antibiotics
o Leave open
76
General concepts in the treatment of puncture wounds
- The aggressiveness of treatment is based on the zone of involvement
- I&D is the cornerstone of treatment
- Antibiotics are carefully considered
- Timing is extremely important
- Always get X-ray
- KEY – EVERYTHING we learned about in infection plus ZONE OF INVOLVEMENT***
