deadly soft tissue infections - squ.edu.om of medicine/departments... · objectives •to be able...
TRANSCRIPT
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