Deadly soft tissue infections. Dr. Faisal Al sawafi Emergency Physician Ibra Hospital
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1 Deadly soft tissue infections Dr. Faisal Al sawafi Emergency Physician Ibra Hospital
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3 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
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5 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
6 Anatomy
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8 importance Common Vague presentations and difficult examinations. MRSA
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10 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
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14 Risk factors DM Hospitalization Admission in ICU Previous antibiotic use Endotracheal intubation with MV Nasogastric or gastrotomy tube Foleys catheter Immunosuppression or chronic illness
15 Absence of risk factors does NOT exclude MRSA because About 50% have no risk factors
16 Diagnosis On clinical background Any skin or soft tissue infections or sepsis
17 Treatment Miller LG, et al. Clin Infect Dis. Fridkin SK, et al. N Engl J Med.
18 Susceptibility patterns are dynamic & vary geographically
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20 Variable sensitivity Clindamycin (83-95%) Tetracycline (81-92%) Ciprofloxacin (15-79%) Erythromycin (6-44%)
21 Case 2
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23 Ludwigs angina Cellulitis of submandibular and subligual space 50 80% : bad dental hygiene
24 Why it is deadly Life threatining, rapid aggressive difficult airway management Mortality 5-10%
25 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
26 Signs and symptoms Febrile, neck pain, odynophagia, dysphagia, drooling, leaning forward. Tender, symmetrical swelling in submandibular area. Cyanosis, tachypnea, stridor, agitation
27 Diagnosis
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29 Treatment Airway Airway Airway
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31 Antibiotics Pinicillins with clindamycin Ampicillin-sulbactam, metronidazole and penicillin, imipenim-cilastatin, piperacillin-tazobactem MRSA coverage
32 contraversial Steroids
33 Surgery Not responds to medical therapy Crepitus and purulent secretions
34 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
35 Periorbital cellulitis
36 Orbital cellulitis
37 Orbital cellulitis Ocular emergency. Infection of tissue posterior to orbital septum. Caused by : ethmoidal sinusitis, endophthalmitis, trauma, poor dental hygiene
38 Organism Staph aureus Strep. pneumoniae H.influena
39 Why it is deadly? Orbital abscess Brain abscess osteomyelitis Meningitis Cavernous sinus thrombosis
40 signs Periorbital redness and swelling Decrease visual acuity Proptosis Chemosis Double vision Limitation of eye movement.
41 CT Diagnosis
42 Treatment Antibiotics (aerobea and anaerobes) 2 nd or 3 rd generation cephalosporin Ampicillin sulbactem Carbapenems Fluroquinolones (penicillin allergy) Metronidazole or clindamycin for anaeobes
43 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
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45 Necrotizing fasciitis
46 Why it is deadly Extensive soft tissue infection Systemic toxicity High morbidity Mortality is 25 35%
47 Risk factors Age DM Peripheral vascular disease Alcoholism Heart disease Renal and heart failure Cancer, hiv
48 Microbiology Type 1 polymicrobial : Type II monomicrobial : (staphylococcus, streptococcus, clostridim species and MRSA) Type III : vibrio vulnificus
49 Clinical features Pain out of proption on physical examination Redness, tenderness Crepitus Fever tachycardia
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51 Diagnosis: XRAY
52 US
53 CT ; sensitivity 80%
54 Treatment Early resussitation Packed RBC transfusion Empirical antibiotic (ampicillin sulbactam, 3 rd cephalo, carbapenem) Surgical consult Operative exploration
55 Fourniers gangrene
56 Clostridial myonecrosis
57 Caused by : clostridim prifingens Deadly : limb and life threatinng Treatment : penicillin + clindamycin
58 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
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60 Why it is deadly Acute fast spread of infection Systemic toxicity Limb threatining
61 Risk factors Immunocompromized Peripheral vascular disease Lymphedema Skin breakdown venous insufficiency
62 Microbiology 80 % gram positive Beta-hemolytic streptococci Staph aureus (MRSA) Less common Haemophilus influenza Organisms from animal or human bites
63 Diagnosis Inflammatory markers Blood culture Needle aspiration Culture of pus, bullae US +- doppler clinical
64 cobblestoning US finding of cellulitis
65 Treatment For outpatient: cephalexin or clindamycin or tetracyclin Inpatient : vancomycin, clindamycin, linezolid and daptomycin
66 MRSA coverage If purulent discharge Penetrating trauma Known MRSA colonization IV drug use
67 Toxic shock syndrome toxin-mediated bacterial skin syndrome
68 Why deadly soft tissue infection Bacteremia is common with positive blood cultures in about 60%. Serious multisystem complications are common, including : DIC, RF, ARDS
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71 Treatment Critical care resuscitation Removal of potential source Antibiotics including clindamycin and vancomycin Surgical consultation
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75 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
76 Thanks alot
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Barbara McInnis House Initial Referral Form Please fill form out completely. Include additional forms if prompted. Fax to Admissions Department. Follow up with a phone call. Patient Name: DOB: Gender:
Department of Surgery
What is emphysema? 2004 Regents of the University of Michigan Emphysema is a chronic disease of the lungs characterized by thinning and overexpansion of the lung-like blisters (bullae) in the lung tissue.