Soft tissue infections   This is a short summary of the lecture, just to ease learning at home

Soft tissue infections This is a short summary of the lecture, just to ease learning at home PowerPoint PPT Presentation

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Soft tissue infections This is a short summary of the lecture, just to ease learning at home

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1. Dr. Madách Krisztina, 2008 Soft tissue infections This is a short summary of the lecture, just to ease learning at home Krisztina Madách

2. Dr. Madách Krisztina, 2008 Which is the largest organ of the body? The skin: Barrier to infection After birth, colonization with mostly nonpathogenic bacteria:103-106/cm2 Infection: bacteries invade surrounding tissues

3. Dr. Madách Krisztina, 2008 Source of infection pathogens (virulent bacteria) or less virulent bacteria in case of imparement of host defence: Local Trauma Tissue oedema Hematoma Ischemic tissue Foreign body Systemic Diabetes mellitus Malignancies Malnutrition Cirrhosis Advanced age Atherosclerosis Neutropenia Steroids-other antiinflammatory drugs

4. Dr. Madách Krisztina, 2008 Terminology of soft tissue infection Multiplicity and inconsistency of terms

5. Dr. Madách Krisztina, 2008 Cutaneous cellulitis (level 1) Nonpyogenic infection limited to skin and superficial subcutenaous tissue Spreading erythema, edema Treatment antibiotics Pay attention! Deep necrotizing infections may have identical external appearance

6. Dr. Madách Krisztina, 2008 Subcutaneous abscess (level 2) Resolves rapidly with incision/drainage Antibiotics needed in case of impared host defence or poorly localized infection

7. Dr. Madách Krisztina, 2008 Necrotizing fasciitis (level 3) Infection spreading along the fascia (little resistance to the lateral spread of bacteria) RAPID! Origin can be: Puncture wound Surgical incision Chronic ulcer Deep abscess Treatment: surgical débridement, parenteral antibiotics

8. Dr. Madách Krisztina, 2008 Muscular infections (level 4) Life threatening (eg. Clostridium perfringens exotoxins) Treatment: radical débridemenet, amputation, parenteral antibiotics, HBOT

9. Dr. Madách Krisztina, 2008 Confounding terms Gas gangrene: popular term for Clostridial myonecrosis, but the presence of gas is neither mandatory nor diagnostic criteria Gas can occur in tissues Surgical intervention Irrigation with H2O2 Ptx, trachea-, oesophagus disruption Dermal necrosis (gangrene): is not synonym with infection! It can be: Ischemia (dry gangrene) DIC after sepsis (purpura fulminans) Streptococcal necrotizing fasciitis (streptococcal gangrene) Clostridial myonecrosis (gas gangrene)

10. Dr. Madách Krisztina, 2008 Causes of dermal necrosis Trauma: Heat/cold injury Mechanical injury Anoxia: Thrombosis/embolism Atherosclerosis Vasculitis Toxic agents: Extravasation of Hypertonic solutions, cytotoxic agents, vasoconstrictors Bacterial toxins Venomous bites

11. Dr. Madách Krisztina, 2008 Pathogens associated with skin infections

12. Dr. Madách Krisztina, 2008 Infection syndromes defined by organism and tissue level (after D.H.Ahrenholz)

13. Dr. Madách Krisztina, 2008 Treatment key-points Antibiotics Surgical débridement

14. Dr. Madách Krisztina, 2008 Infections responding to antibiotics

15. Dr. Madách Krisztina, 2008 Indication for surgical exploration Local Cellulitis Spreading despite antibiotic treatment In haematoma or surgical wound Abscess with multiple tracts Severe pain os spreading anesthesia Thin drainage from wound with undermined edges Cyanosis, bronzing, necrosis of skin Impaired motion or muscle strength Wound crepitus or radiographic signs of gas

16. Dr. Madách Krisztina, 2008 Indication for surgical exploration Systemic Tachycardia/tachypnoe Hypovolaemic shock Changes in mental state Hyperglycaemia/ketoacidosis thrombocytopenia/leukopenia

17. Dr. Madách Krisztina, 2008 Necrotizing fasciitis Any necrotizing soft tissue infection spreading at the level of fascia 2300 years ago Hippocrates graphically described the consequences of untreated erysipelas US civil war: „hospital gangrene” 1924 Meleney isolated Streptococcus pyogenes: „hemolytic streptococcal gangrene”

18. Dr. Madách Krisztina, 2008 Necrotizing fasciitis Etiology-Pathogenesis S.pyogenes or a combination of bacteria At fascial level there are few barriers of lateral spread Origin: minor wound or chronic ulcer Iv drug abusers enteric organisms at perineal sites contaminated abdominal operations can complicate any surgical procedure! can complicate varicella children

19. Dr. Madách Krisztina, 2008 Necrotizing fasciitis Diagnosis A challenge…. Pain, edema, fever, leukocytosis Identification of streptococci in wound fluid Plain radiographs CT MRI Needle aspiration of the inflamed area may recover infected fluid (80%) Biopsy

20. Dr. Madách Krisztina, 2008 Necrotizing fasciitis Treatment Early surgical débridement is critical!!! Extensive radiographic examinations are contraindicated in face of spreading infection (time-loss) Preoperative antibiotics (Gram’s stain of wound) Antibiotics: combination (piperacillin/tazobactam+clindamycin) Intraoperative aerob/anaerob cultures of tissue and fluid Streptococcal toxic shock sy: IVIG Failure to completely remove necrotic tissue results in rapidly fatal course The skin flaps may not survive: delayed skin grafting Agressive nutritional support

21. Dr. Madách Krisztina, 2008 Necrotizing fasciitis Prognosis Risk factors: diabetes mellitus, malnutrition, hypertension, drug abuse Presence of > 3 of risk factors increase mortality from 17 to 79% (Francis et al.)

22. Dr. Madách Krisztina, 2008 Nonclostiridial myonecrosis Represents the end-tage of necrotizing fasciitis, usually in patients with impared host defenses (etiology, diagnosis, treatment is similar) Prognosis: mortality > 76%! Survival depends on radical necrectomy (almost all survivors had extremity infection-amputation)

23. Dr. Madách Krisztina, 2008 Clostridial myonecrosis Etiology-Pathogenesis Wartime injuries, farm machinery/motor vehicle accidents, GI-biliary tract operations, criminal abortions C.perfringens, novyi, septicum spores (may lay inactive for long periods) release lethal toxins Differs from other wound infections by the presence of severe systemic toxicity, confusion, local pain, Gram-pos rods in the wound fluid. Soft tissue gas is present in 40% of cases.

24. Dr. Madách Krisztina, 2008 Clostridial myonecrosis Iv penicillin 12-20 million U/day /Clindamycin and operation, HBOT Rising CK suggests uncontrolled muscular sepsis Mortality: 20-25% agressive debridement, open treatment, AB, HBOT

25. Dr. Madách Krisztina, 2008 Hyperbaric Oxygen treatment (HBOT)

26. Dr. Madách Krisztina, 2008 Case reports and certain photos (only allowed to be presented at lectures) were taken out from this material due to ethical reasons. Wishing you easy learning, Dr. Madách Krisztina

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