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PubMed1998

Soft tissue infections.

Soft tissue infections vary widely in their nature and severity, and their nomenclature is confusing. A clear approach to management must allow rapid identification and treatment of the diffuse necrotizing infections because they are life-threatening. This review classifies soft tissue infections by their degree of localization and the presence of tissue necrosis. Most focal nonnecrotizing infections start in the skin or adnexae and are easily recognized and readily treated by local measures. Patients with cellulitis, the commonest diffuse nonnecrotizing infection, should be stratified from mild to severe and complicated and then treated with oral or systemic antibiotics. Focal necrotizing infections are relatively uncommon, but they are readily diagnosed on sight and effectively managed by local debridement and systemic antibiotics. In contrast, diffuse necrotizing infections may masquerade in many forms, delaying diagnosis and treatment. Edema out of proportion to erythema, subcutaneous gas, and skin vesicles are important markers. Aggressive sequential debridement and broad-spectrum intravenous antibiotics revised after 48 hours provide the best strategy for management.

Anti-Bacterial Agents↗

PubMed1990

[Etiology, diagnosis and therapy of soft tissue infections].

Soft tissue infections are caused by a multitude of bacteria. Their pathogenicity depends on the ability to adhere to surfaces, certain characteristics of the cell wall, exoenzymes or exotoxins, and endotoxins. Because etiologic classification of soft tissue infections is not satisfactory, we propose a clinical classification. 1. Abscesses are caused by staphylococci (carbuncle or suppurative hydroadenitis) or by polymicrobial infections (most subcutaneous abscesses). They are treated by incision and drainage and primary closure of the skin after drainage and curettage is often successful. Only in special cases are antibiotics indicated. 2. Cellulitis mostly caused by streptococci responds well to antibiotic therapy without surgery. 3. Ulcerative lesions i.e. pseudomonal gangrene and Meleney's gangrene need specific antibiotic therapy and complete excision with delayed grafting.

Abscess↗

PubMed1990

Impact of the antibiotic dosage schedule on efficacy in experimental soft tissue infections.

Soft tissue infection models have been used to study both the postantibiotic effect (PAE) and the effect of dosage intervals on antimicrobial efficacy. In vitro findings were mostly confirmed. For drug-organism combinations which showed a predominantly time-dependent killing pattern and absence of a PAE (beta-lactams vs Gram-negative organisms), frequent drug dosing was most efficacious. In contrast, a fast, predominantly concentration-dependent bactericidal effect followed by a PAE in vitro (e.g. aminoglycosides vs Gram-negative bacteria) correlated (though inconsistently) with superiority of bolus dosing over more continuous drug administration in vivo. Thus, the ratio of peak serum concentrations to MICs of target pathogens is possibly a valid predictor of efficacy for the aminoglycosides but not so for the activity of beta-lactam antibiotics where the duration of coverage at supra-MIC levels was clearly more important than the magnitude by which initial peaks exceeded the MIC of the target organism. It is not clear to what extent the results obtained in experimental soft tissue infections may hold true in man. Thus far, only a limited number of drug-organism combinations have been studied in well defined experimental settings using mostly small, granulocytopenic animals which differ pharmacokinetically from man. In addition, results are probably affected by the density of bacteria, their growth rate and metabolic activity, but also by the extent of inflammation at the site of infection.

Animals↗

PubMed1993

[Necrotizing soft tissue infections].

Necrotizing soft tissue infections are a group of life- and limb-threatening infections. They are caused by aerobic and anaerobic bacteria occasionally in a synergistic polymicrobial combination. The literature describing necrotizing soft tissue infections is controversial and often contradictory. Depending on their clinical appearance, tissue level and microbiological findings, necrotizing soft tissue infections are classified into two major groups, infections within the subcutaneous/fascia niveau and within the muscle level. Necrotizing infections of the subcutaneous level are further differentiated in hemolytic streptococcal gangrene, necrotizing fasciitis, clostridium fasciitis, and anaerobic nonclostridium fasciitis. In particular, necrotizing fasciitis is a rapidly progressing process, which is characterized by suppurative fasciitis, following by vascular thrombosis and cutaneous gangrene and is often accompanied by severe systemic toxicity, seen as septic-toxic shock and progressive (multi-) organ failure. Nineteen cases of necrotizing soft tissue infections were treated at the Department of Surgery, University Hospital of Zurich, between 1989 and 1992. These infections originated from "neglected trauma" in 9 (9/19), drug injections in 4 (4/19), acute infections in 3 (3/19), operative wounds in 2 (2/19) and perforation of the intestine in 1 case (1/19). Most of the patients (13/19) suffered from chronic debilitating diseases and were compromised by a suppressed immune system. We treated two groups of patients, one with septic-toxic clinical course and the other without. Eleven patients (11/19) belonged to group one and four of them, showing necrotizing fasciitis of the trunk, died as a result of multiorgan failure (MOF). Furthermore, three patients in this group had a limb amputated. In the other group without septic-toxic signs, no one died or lost a limb. The two groups differed also in length of hospital stay, an average of 60 days in group one (23 days intensive care) and 25 days in group two. Our results suggest that prompt recognition and treatment of necrotizing soft tissue infections are essential for the patient's survival. Often the full extent of the infections is underestimated initially, resulting in delayed surgical therapy. To control the rapidly spreading necrosis, early diagnosis and radical debridement of the affected tissue are essential and should be done without compromise, even if the affected limb must be amputated.

Adult↗

PubMed1988

Mead Johnson Critical Care Symposium for the Practising Surgeon. 5. The diagnosis and management of common soft-tissue infections.

Soft-tissue bacterial infections range from the superficial, relatively benign form, readily treated by oral administration of antibiotics, to the highly lethal variety which requires extensive surgical débridement, administration of broad-spectrum antibiotics and patient monitoring in the intensive care unit. The key to patient survival in the latter group is early diagnosis and treatment. Those at risk of serious infections include diabetic and cirrhotic patients and trauma victims who have been treated either surgically or medically. In addition to awareness of the possibility of serious infection, x-ray films of the soft tissue to show gas, aspiration of fluid collections for Gram's staining and local incision of the tissue to inspect fascia and muscle are all useful aids in diagnosis. This review attempts to classify soft-tissue infections and to recommend an approach to diagnosis and management.

Bacterial Infections↗

PubMed1998

Aspergillus: a rare primary organism in soft-tissue infections.

Nonclostridial necrotizing soft-tissue infections are usually polymicrobial, with greater than 90 per cent involving beta-hemolytic streptococci or coagulase-positive staphylococci. The remaining 10 per cent are usually due to Gram-negative enteric pathogens. We describe the case of a 46-year-old woman with bilateral lower extremity fungal soft tissue infections. She underwent multiple surgical debridements of extensive gangrenous necrosis of the skin and subcutaneous fat associated with severe acute arteritis. Histopathological examination revealed Aspergillus niger as the sole initial pathogen. Despite aggressive surgical debridement, allografts, and intravenous amphotericin B, her condition clinically deteriorated and she ultimately died of overwhelming infection. Treatment for soft-tissue infections include surgical debridement and intravenous antibiotics. More specifically, Aspergillus can be treated with intravenous amphotericin B, 5-fluorocytosine, and rifampin. Despite these treatment modalities, necrotizing fascitis is associated with a 60 per cent mortality rate. Primary fungal pathogens should be included in the differential diagnosis of soft-tissue infections.

Aspergillosis↗

PubMed1992

Soft tissue infections.

Infections in soft tissues present with one or more of the cardinal signs of infections; however, presence of these signs may indicate manifestation of a deep systemic infection or of a noninfectious process. One of the earliest determinations to be made is whether the problem is likely to require patient admission or referral to another specialty. Only then is the primary management clear.

Bacterial Infections↗

PubMed1996

Necrotizing soft-tissue infections.

Necrotizing soft-tissue infections may be rapidly fatal because of toxin-induced circulatory collapse. Because of the often nonspecific clinical presentation, prompt diagnosis may be difficult but is imperative as prompt treatment can be lifesaving. This article discusses necrotizing fasciitis and clostridial myonecrosis, and highlights pathogenesis, clinical presentation, diagnosis, and treatment.

Diagnosis, Differential↗

PubMed1992

Necrotizing soft-tissue infections.

Necrotizing soft-tissue infections have been widely recognized for over a century, but they remain a challenging problem in clinical infectious disease. Patterns of disease are clearly apparent, but most are polymicrobial and derive increased virulence from synergy between bacteria. Early recognition and prompt surgical drainage are the keys to successful treatment. Edema extending beyond the area of erythema, skin vesicles, crepitus or air in the subcutaneous tissues, and absence of lymphangitis and lymphadenitis are markers of necrotizing infections, particularly when they occur in patients with serious underlying disease. Empiric broad-spectrum antibiotics, prophylactic heparin, and nutritional therapy are important adjuncts to aggressive "stepwise" surgical debridement. A knowledge of patterns of disease can aid in fine-tuning treatment to decrease morbidity.

Gangrene↗

PubMed1975

Needle aspiration in the diagnosis of soft tissue infections.

Diagnosis of soft tissue infections is often delayed or made incorrectly because of reliance on indirect means to determine the etiologic agent. A rapid, speific method is the needle aspiration of these lesions combined with Gram-stain and culture studies. More frequent use of this direct method should facilitate diagnosis and improve treatment. Seven case studies are present to illustrate the usefulness of this technique.

Abscess↗

PubMed1995

Identifying high risk patients for Staphylococcus aureus infections: skin and soft tissue infections.

Staphylococcus aureus is the causative organism for many skin and soft tissue (SST) infections. Some SST infections have severe systemic complications, such as bacteraemia and sepsis. S. aureus is the cause of 75% of primary pyodermas. Pre-existing conditions, like tissue injury (ulcers, wounds) or tissue inflammation (exudative dermatitis), and also underlying disorders (such as poorly controlled insulin-dependent diabetes mellitus or cancer) are some of the risk factors for secondary infection with S. aureus. In S. aureus-infected primary skin disorders (impetigo, recurrent eczema), 2% mupirocin ointment has proved effective in several clinical trials. S. aureus is responsible for 25% of all burn-wound infections, and burn units could be the point of entry and source of spread of methicillin-resistant S. aureus infection outbreaks. Mupirocin (2% ointment) has also proven effective for topical treatment of these infections. Pressure sores develop in 6% of all patients admitted to acute and chronic health care institutions. An average of three aerobic species (including S. aureus) plus one anaerobic species are isolated when infected. Infectious complications are responsible for 60-80% of all intravenous drug user (IVDU) hospital admissions, 5-20% being due to S. aureus infective endocarditis (IE). The origin of IE in IVDUs is probably the skin. Data from a Collaborative Spanish Study of IVDU infectious complications (including more than 10,000 episodes) are discussed.

Burns↗

PubMed1990

Pefloxacin versus ceftazidime in therapy of soft tissue infections in compromised patients.

Soft tissue infections in compromised patients are frequently caused by Gram-negative organisms and particularly by Pseudomonas aeruginosa. These pathogens are effectively eradicated by pefloxacin as well as by ceftazidime. The effectiveness and safety of these two agents were compared in a prospective randomized study in 67 patients with soft tissue infections. Underlying conditions included malignant diseases, diabetes mellitus and chronic renal failure. The infections included: post operative infection, septic foot, soft tissue abscess and cellulitis. Thirty-three patients were treated with intravenous ceftazidime for a mean duration of ten days. More than half the 34 patients given pefloxacin were treated only orally for a mean period of 13 days. The clinical and bacteriological outcomes were similar in both groups. There was clinical cure or improvement in 26 pefloxacin cases and in 23 ceftazidime cases, failure in six pefloxacin cases and in seven ceftazidime and relapse in two pefloxacin and in three ceftazidime patients. The bacteriological responses were eradication in 23 pefloxacin cases and in 22 ceftazidime cases, persistence in five pefloxacin cases and in six ceftazidime cases, relapse in one pefloxacin case and in none of the ceftazidime group, reinfection in four pefloxacin cases and in three ceftazidime cases and there was one unassessed patient in the pefloxacin group and two in the ceftazidime group. Nausea and vomiting occurred in three patients and elevation of liver enzymes in another patient; all side effects were observed only in the pefloxacin treated patients. These results suggest that oral pefloxacin could offer an alternative to intravenous ceftazidime in half the compromised patients with tissue infections. However, adverse reactions due to pefloxacin administration should be watched for during such therapy.

Administration, Oral↗

PubMed1993

Intervention to discontinue parenteral antimicrobial therapy in hospitalized patients with urinary tract infection, skin and soft tissue infection, or no evident infection.

OBJECTIVES: In a previous study, we found that unsolicited recommendations to physicians of medically stable patients with pneumonia to suspend parenteral antimicrobials shortened hospital length of stay (LOS) significantly. In this study, we made similar recommendations to physicians treating patients with different indications for parenteral antimicrobials, to examine the effect on LOS. METHODS: A nurse-interventionist presented randomly assigned physicians with nonconfrontational suggestions to discontinue parenteral antimicrobials by substituting comparable oral antimicrobials or stopping treatment. Patients were being treated for urinary tract infection, skin infection, or no evident infection. Blinded observers evaluated in-hospital and 30-day postdischarge patient courses. Methodologies were identical to the previous study. RESULTS: There were 70 physician-patient episodes (49 intervened episodes, 21 control episodes). In 44 episodes (90%), compliant physicians discontinued parenteral antimicrobials. Compared to a median postrandomization LOS of 2.5 days (range, 0 to 40.5) for 21 patients of control physicians, the corresponding LOS for 44 patients of compliant physicians was two days (range, 0 to 8; P = 1.0), and for five patients of noncompliant physicians, five days (range, 3 to 11; P = 0.04). The combined occurrence of all adverse events detected in this and the previous study was 11% for patients of control physicians, compared to 14% for patients of compliant physicians (P = 0.2), and 19% for patients of noncompliant physicians (P < 0.05). CONCLUSIONS: For patients of compliant physicians hospitalized with urinary tract infection, skin and soft tissue infection, or no evident infection, cessation of parenteral antimicrobials did not significantly shorten LOS, due to brief LOS of patients of control physicians. Patients of noncompliant physicians experienced more adverse events and prolonged LOS. The appropriateness of routine continuous use of parenteral antimicrobials in medically stable inpatients is questioned.

Aged↗

PubMed1990

Topical liposomal delivery of antibiotics in soft tissue infection.

A new drug delivery system (lipid microcarriers) was studied in an experimental model of infected soft tissue wounds. Superficial, nonlethal infection was produced in the adult rat by injecting 1 ml containing 10(8) colony-forming units (CFU) of Pseudomonas aeruginosa under the superficial fascia of the paraspinus muscle of a 2-cm2 excised wound. All wounds were dressed with N-Terface, a nonadherent wound material, and covered with Kontor sponge, an open-cell polyurethane sponge containing either normal saline (group I), free tobramycin (groups III and V), liposome-entrapped tobramycin (groups II and IV), silver sulfadiazene (group VI), or liposome-entrapped silver sulfadiazene (group VII). At 24, 48, and 72 hr postinjection, animals were sacrificed and colony-forming units of P. aeruginosa per gram of muscle tissue were determined. Group I had significantly higher colony-forming units of P. aeruginosa per gram than groups II and III at 48 and 72 hr and than groups IV and V at all times. One single dose of liposome-encapsulated silver sulfadiazine significantly decreased bacterial counts compared to untreated controls and, to a similar extent, compared to multiple applications of free drug. Colony-forming units in all treatment groups (II and III, IV and V, VI and VII) were similar at all time periods within equivalent dosages. The ability of one application of liposomal-entrapped antibiotics to result in a therapeutic effect that requires multiple applications of topically applied free antibiotics offers potential clinical advantages.

Administration, Topical↗

PubMed1998

Molecular analysis of the role of the group A streptococcal cysteine protease, hyaluronic acid capsule, and M protein in a murine model of human invasive soft-tissue infection.

Human invasive soft-tissue infections caused by group A Streptococcus are associated with significant morbidity and mortality. To investigate the pathogenesis of these serious infections, we characterized the host response to bacterial challenge with an M-type 3 isolate recovered from a patient with necrotizing fasciitis, or with isogenic gene replacement mutants deficient in cysteine protease, hyaluronic acid capsule, or M protein in a murine model of human invasive soft-tissue infection. Animals challenged with the wild-type or cysteine protease-deficient strain developed spreading tissue necrosis at the site of inoculation, became bacteremic, and subsequently died. Histopathologic examination of the necrotic lesion revealed bacteria throughout inflamed subcutaneous tissue. Arterioles and venules in the subcutaneous layer were thrombosed and the overlying tissue was infarcted. In contrast, animals challenged with either an acapsular or M protein-deficient mutant developed a focal area of tissue swelling at the site of inoculation without necrosis or subsequent systemic disease. Histopathologic examination of the soft-tissue lesion demonstrated bacteria confined within a well-formed subcutaneous abscess. We conclude that the group A streptococcal hyaluronic acid capsule and M protein, but not the cysteine protease, are critical for the development of tissue necrosis, secondary bacteremia, and lethal infection in a murine model of human necrotizing fasciitis.

Abscess↗

PubMed1998

[Possibilities of preliminary treatment of infected soft tissue defects by vacuum sealing and PVA foam].

The vacuum sealing technique is a simple and cost-effective method in the treatment of traumatic and chronic soft-tissue defects. Wound cavities are filled with polyvinyl alcohol foam with embedded drainage tubes. The tubes are either drawn transcutaneously through the tissue, or placed epicutaneously, depending on the condition of the wound. The wound including the adjacent skin and the drainage tubes are covered by a transparent vapor transmitting polyurethane film. When the drainage tubes are connected with a vacuum bottle, negative pressure of 60 to 80 kPa is established. The advantages of this vacuum sealing procedure are: protection against wound contamination, complete evacuation of wound fluids independent of gravity and rapid stimulation of dense, well vascularized granulation tissue. Relief of pain and early mobilisation improve the patients comfort. Between November 1994 and July 1996, 25 patients with 28 soft tissue defects underwent this procedure. Wound closure was performed in two cases with a free flap, in five cases by a loco-regional flap, in sixteen cases with mesh-grafts, in three cases by secondary closure of the wound. Two cases were definitively treated with the vacuum sealing technique.

Adolescent↗

PubMed1996

Soft tissue infections and the diabetic foot.

Soft tissue infections are classified as local or spreading. Spreading soft tissue infections are potentially life-threatening conditions, requiring prompt diagnosis and treatment. The information presented is based on a literature review and the authors' clinical experience. Diagnosis of soft tissue infections is aimed at determining the level of infection (skin, fascia, muscle) and whether necrosis is present. The bacteriology of these infections is varied and is of secondary importance. Treatment of skin infections that have no dead tissue is with antibiotics alone. Infections at the fascial or muscle level and those with necrosis at any level require surgical debridement and adjuvant antibiotics. The feet of diabetic patients are prone to plantar forefoot ulcers associated with tissue destruction and infection. The vast majority are caused by mechanical factors. If local immune defenses are adequate, bacterial colonization occurs without infection. Most diabetic foot ulcers will respond to relief of pressure, which may require total contact casting. Antibiotics and debridement are required in infected or deep ulcers, or when the ulcer does not respond to total contact casting.

Anti-Bacterial Agents↗

PubMed1991

Ceftriaxone in treatment of serious infections. Skin and soft tissue infections.

Ceftriaxone is generally recognized to be safe and effective when administered either intravenously or intramuscularly to both adults and children as a single drug for skin and skin structure infections. An advantage of ceftriaxone over the other third-generation cephalosporins is its long serum half-life, which allows it to be given every 12 hours in children and every 24 hours in most adults. There is no question that ceftriaxone is effective for skin and soft tissue infections, particularly those caused by staphylococci and streptococci. The drug's sales to home infusion companies around the country attest to its widespread use for such infections. The fact remains, however, that the data required to substantiate efficacy and safety for ceftriaxone or for any of the other third-generation cephalosporins are just not available in large numbers.

Adult↗