Necrotizing soft tissue infections: Difference between revisions
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*Imaging | *Imaging | ||
**CT | **CT | ||
===Diagnosis=== | ===Diagnosis=== | ||
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**CT | **CT | ||
*** | *** | ||
===Treatment=== | |||
#Surgical exploration and debridement | |||
##Indicated in setting of severe pain, toxicity, fever, elevated CK, w/ or w/o radiographic evidence | |||
#Abx | |||
##Must cover Gram +/- and anaerobes (esp GAS and clostridium) | |||
##Piperacillin-tazobactam 3.375-4.5g q6hr AND clindamycin 600-900mg q8hr AND vancomycin 1gm IV q12hr | |||
==Necrotizing Myositis== | ==Necrotizing Myositis== | ||
===Background=== | |||
* Much rarer than nec fasc | * Much rarer than nec fasc | ||
* May be preceded by skin abrasions, blunt trauma, heavy exercise | * May be preceded by skin abrasions, blunt trauma, heavy exercise | ||
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*Overlying skin changes may manifest later in the course of illness (erythema, warmth, petechiae, bullae) | *Overlying skin changes may manifest later in the course of illness (erythema, warmth, petechiae, bullae) | ||
*Hypotension may occur rapidly with development of streptococcal toxic shock syndrome | *Hypotension may occur rapidly with development of streptococcal toxic shock syndrome | ||
===Management=== | |||
* Same as necrotizing fasciitis (see above) | |||
==Necrotizing Cellulitis== | ==Necrotizing Cellulitis== | ||
===Background=== | |||
*Pts are often much less toxic compared with nec fasc/nec myo | *Pts are often much less toxic compared with nec fasc/nec myo | ||
* Two types: | * Two types: | ||
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===Management=== | ===Management=== | ||
* | *Same as necrotizing fasciitis (see above) | ||
==Source== | ==Source== | ||
Revision as of 22:52, 21 March 2013
Background
- Includes necrotizing forms of cellulitis, myositis, and fasciitis
- Two types:
- Type 1: polymicrobial infection
- Type 2: group A strep
- May occur in healthy individuals
- May occur via hematogenous spread from throat to site of blunt trauma
Necrotizing Fasciitis
Risk Factors
- DM
- Drug use
- Obesity
- Immunosuppression
- Recent surgery
- Traumatic wounds
Clinical Features
- Skin exam
- Erythema(without sharp margins)
- Exquisitely tender (pain out of proportion to exam)
- Skip lesions
- Hemorrhagic bullae
- May be preceded by skin anesthesia (destruction of superficial nerves)
- Crepitus (in type I infections)
- Swelling/edema may produce compartment syndrome
- Constitutional
- Fever
- Tachycardia
- Systemic toxicity
Work-Up
- Labs
- CBC
- Chem
- PT/PTT/INR
- CK
- Lactate
- Imaging
- CT
Diagnosis
- Surgical exploration is the only way to definitively establish the diagnosis of necrotizing infection
- Imaging
- Should not delay surgical exploration
- CT
Treatment
- Surgical exploration and debridement
- Indicated in setting of severe pain, toxicity, fever, elevated CK, w/ or w/o radiographic evidence
- Abx
- Must cover Gram +/- and anaerobes (esp GAS and clostridium)
- Piperacillin-tazobactam 3.375-4.5g q6hr AND clindamycin 600-900mg q8hr AND vancomycin 1gm IV q12hr
Necrotizing Myositis
Background
- Much rarer than nec fasc
- May be preceded by skin abrasions, blunt trauma, heavy exercise
- Most patients are otherwise healthy (DM and other underlying conditions do not appear to increase risk)
Clinical Features
- Exquisite pain and swelling of affected muscle with induration
- Overlying skin changes may manifest later in the course of illness (erythema, warmth, petechiae, bullae)
- Hypotension may occur rapidly with development of streptococcal toxic shock syndrome
Management
- Same as necrotizing fasciitis (see above)
Necrotizing Cellulitis
Background
- Pts are often much less toxic compared with nec fasc/nec myo
- Two types:
- Anaerobic infection (clostridial and nonclostridial)
- Meleney's synergistic gangrene
- Rare infection that occurs in postop pts
- Characterized by slowly expanding indolent ulceration that is confined to superficial fascia
- Results from synergistic interaction between S. aureus and microaerophilic streptococci
Risk Factors
- Trauma
- Surgical contamination
- Spread of infection from bowel to perineum, abdominal wall, or lower extremities
Clinical Features
- Thin, dark, sometimes foul-smelling wound drainage (often containing fat globules)
- Tissue gas formation (crepitus)
Management
- Same as necrotizing fasciitis (see above)
Source
- UpToDate