Soft Tissue Infections
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Soft Tissue Infections
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Abscess An ABSCESS is localised collection of pus in the body. Pus is composed of neutrophils, exudate and bacteria
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The result of “skin popping” -Multiple injection site abscesses
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Causative Organisms Staphylococcal organisms(most common staphylococcus aureus) Streptococcal organisms Gram Negative Bacteria E. coli Pseudomonas Klebsiella Anaerobes
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Types Pyogenic Abscess Pyaemic Abscess Metastatic Abscess Cold Abscess
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Causes Direct infection from outside due to penetrating wound Local extension from adjacent focus of infection Lymphatics Blood stream or Haematogenous spread
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Sometimes the abscess cavity persists,which becomes firm and contains sterile pus this is known as ANTIBIOMA Firmness is due to thickness of its wall
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Clinical Features Throbbing Pain(Due to pressure on nerve endings by the pus) Brawny induration around Fever with or without chills & rigors Cardinal features of inflammation are present Redness or Rubor due to hyperaemia Swelling or tumor Pain or Dolar Heat or Calor Loss of function or Functiolaesa
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Investigations All routine Examinations USG abdomen CXR CT Scan Specific Tests
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Treatment Basic principle-“Where there is pus,let it out” To drain the pus To send a sample for culture and sensitivity test To give proper antibiotic First wait for the localisation of the pus,till that time conservative treatment-affected part is elevated and given rest and suitable antibiotic
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Drainage of PUS Free or liberal incision Hilton’s method Particularly in places like Neck Axilla & Groin
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PYAEMIC ABSCESS This occurs due to lodgement of septic emboli,consisting of clump of organisms,infected clot or vagitations,formed as a result of breaking up of an infected thrombus. Pyaemia is associated with Acute osteomyelitis Acute bacterial endocarditis Acute inflammation of intracranial sinus
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Characterstic Features They are multiple They are deep seated Tenderness is minimal No local rise in temperature “It is also called nonreactive abscess”
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Treatment Locate the source of infection & treat as soon as possible. Administer suitable antibiotic parentrally as quick as possioble after culture and sensitivity test of the pus Drain the superficial abscess
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COLD ABSCESS Cold abscess means an abscess which has no signs of inflammation. It occurs due to caseation necrosis of lymph nodes,on palpation soft and matted nodes are usually palpable.
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Causes Tuberculosis Actinomycosis Leprosy Madura foot
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Sites Neck & Axilla(commonest sites) Loin At the side & back of the chest wall Near the end of long bones and joints from bone and joint tuberculosis
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Clinical features No local rise in temperature No tenderness No redness Soft cystic and fluctuant swelling Transillumination is negative
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Treatment After diagnosis is confirmed antitubercular treatment should be started. Non-dependent aspiration(wide bore needle is preferred bcz caseous material is thick) I &D should not be done because it causes persistant sinus
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Definition A sharply demarcated streptococcal infection of the superficial lymphatic vessels, associated with broken skin on the face More superficial than cellulitis
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Etiology • Typically caused by Group A ß-hemolytic Streptococcus
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Sites Orbit Face Scrotum Umbilicus in Infants
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Clinical Features Intense erythema, Induration Sharply demarcated borders (differentiates it from other skin infections) Discharge is serous
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Milian’s Ear Sign Skin of ear lobule can be involved in Erysipelas Will not be involved in Cellulitis
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Complication Septicemia Localized cutaneous and subcutaneous gangrene Lymphedema of face and eyelid
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Treatment Penicillin or first generation cephalosporin (e.G. Cefazolin or cephalexin)
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Carbuncle & Furuncle deeper infections of the hair follicle that extend into the subcutaneous tissue
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Furuncle or boil Small abscess Firm, tender, erythematous nodule Occurs in skin areas exposed to friction ( inner thighs and the axilla) Also face, neck, upper back, and buttocks.
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Predisposing Factors Increased friction and perspiration (obese individuals or athletes), Corticosteroid use, Diabetes mellitus, Inherited or acquired defects in neutrophil function
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Treatment Initial treatment Warm compresses to help promote drainage Oral antimicrobial agent effective against S. Aureus Incision-and-drainage necessary when lesions do not drain spontaneously. Failure to drain these lesions adequately may result in recurrence, as well as in progression to a more serious infection.
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Carbuncle deep cutaneous infection involving multiple hair follicles characterized by destruction of fibrous tissue septa and formation of a series of interconnected abscesses.
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Clinical Features Relatively large skin lesions (confluence) associated with chronic drainage, sinus tracts, and scarring Typically painful, red, tender, indurated area of skin with multiple sinus tracts Systemic manifestations (e.G., Fever and malaise) are common Occurs most frequently on nape of the neck, upper part of the back, or the posterior thigh.
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Treatment Incision-and-drainage w. thorough search for loculated areas should wide local excision of the involved skin and subcutaneous fat to prevent recurrent disease Oral antistaphylococcal agent
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Definition Cellulitis is a non suppurative spreading inflammation of subcutaneous tissue.
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Sources of infection Injuries—major or minor Surgical incision Wound or scratch Snake bite,scorpion bite,etc
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Etiology Skin flora most common organisms S. Aureus, 13-hemolytic streptococcus Immunocompromised gram-negative rods and fungi
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Precipitating factors Diabetes Low immunity
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Common sites Lower limbs Face Scrotum Forearm
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Clinical features Varying degree of fever and toxaemia. Affected part is swollen,warm and painful.Skin is stretched & shiny. Pitting oedema and brawny induration Surrounding lymph vessels may be seen as red streaks due to lymphangitis. Regional lymph nodes are inlarged and tender.
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Different from Abscess Bcz………. No edge(diffuse swelling) No limit No pus No fluctuation “If untreated suppuration,sloughing and gangrene can occur”
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Complications Abscess Necrotising fascitis Toxaemia & Septicaemia Cellulitis can precipitate ketoacidosis in diabetics
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Cellulitis with Abscess Features: Cellulitis present Swollen Soft center, feels like fluid underneath Painful Tender
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Investigations CBC, blood cultures Culture and gram stain wound/aspirate from wound if open wound Plain radiographs if suspect foreign body or abscess R/o bone invasion (osteomyelitis)
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Treatment Rest & elevation of the part to reduce oedema Glycerine & mgso4 dressing which reduces oedema by osmotic effect. Appropriate antibiotics Cephalexin 500 mg PO q6h or cloxacillin 500 mg PO q6h x 7 d If complicated (e.G. Lymphangitis, DM) consider IV cefazolin 1-2 g q8h If patient is diabetic it should be controlled
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Treatment…. Outline area of erythema to monitor success of treatment Immobilize and splint (hands)
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Background An insidiously advancing soft tissue infection. Widespread fascial necrosis. Polymicrobial Most closely linked group A beta-hemolytic. Most cases caused by other bacteria
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Syndromes Type I is polymicrobial Type II is group A strep Type III is gas gangrene or clostridial necrosis. A variant of type I is salt water NF caused by vibrio species.
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Causes Group A beta-hemolytic strep not only cause. Haemophilus, and Staph also associated. Diabetes predisposes a patient to NF. Immunosupression predisposes a patient to NF. Still, 50% occur in young healthy people.
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Causes Type III NF caused by clostridium perfringes. Can occur in association with colon cancer and leukemia. In type II, varicella infection and the use of NSAIDs may be predisposing.
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Morbidity and Mortality Mortality rate as high as 25%. Cases with sepsis and renal failure have a mortality rate as high as 70%.
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Age and History Approximately 50% of cases of streptococcal NF occur in young and previously healthy patients. Begins with fevers and chills. 2-3 days later erythema, vesicles, bullae. Serosanguinous fluid drains from area. Can occur at surgical sites, IV sites, ulcers, bites, many times no previous wound.
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Types Type I usually occurs after trauma or surgery. May be mistaken for simple wound cellulitis, but severe pain and systemic toxicity is a clue to underlying necrosis. Also observed in urogenital or anogenital infections.
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Types Type II is the so-called flesh eating bacterial infection caused by group A strep. Type III, or clostridial necrosis is gas gangrene. This skeletal muscle infection may be associated with trauma or recent surgery.
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Physical General findings include: Rapidly advancing erythema, painless ulcers along fascial planes, black necrotic eschar. Septicemia is typical and leads to severe systemic toxicity, rapid death. Crepitus may be evident in diabetics.
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Physical….. In type II The widespread underlying tissue necrosis can be demonstrated by passing a probe through the tissue. Gas not usual In type I, Bacteria work synergistically to cause what appears to be a simple cellulitis Gas may be evident
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Features Suggesting It Rapid progression Poor therapeutic response Blistering necrosis Cyanosis Extreme tenderness High temperatures, tachycardia, hypotension, altered mental status.
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Laboratory Cannot be relied upon. May facilitate diagnosis, but clinical is more important. WBC>14000, BUN> 15, Na < 135.
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Radiology Standard x-rays of little use. CT more sensitive. MRI and CT can delineate and determine extent of surgical resection.
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Medical Therapy Treat without delay Team approach ICU admission Monitor hemodynamics Antibiotics- combination or single Hyperbaric oxygen
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Antibiotics Combination: cover G- and G+ and anaerobes Ampicillin, gentamycin, Metronidazole Single coverage Imipenem covers aerobes, pseudomonas. Vancomycin for methicillin resistant staph.
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Surgical Care Immediate debridement Do it over and over. Amputation may be required if limb affected. Incisions should be deep and extend to healthy tissue. Excise necrotic areas, irrigate. Dressing changes in OR
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Complications Sepsis and renal failure Metastatic cutaneous plaques Systemic toxicity and death Loss of limb, deformities, psychosocial issues Medical/legal issues.
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Gangrene=Death and decay of body tissue caused by insufficient blood supply Usually following disease, infection, injury, blood vessel disease, or surgery. Thrive where there is no oxygen
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Types and Where Dry Gangrene Wet Gangrene Gas Gangrene Necrotizing Fasciitis
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Dry Gangrene Affects bodies extremities
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Gas Gangrene Just like necrotizing fasciitis except develops deep in body muscles (mostly from surgical wounds) Releases gasses and toxins to kill living tissue, then spreads Loves to be in low oxygen areas
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Sites legs (most common) Feet Toes Fingers limbs Internal organs
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Treatment Conservative treatment involves keeping the affected part absolutely dry. Exposure to the air and the use of a fan may assist in the desiccation process and may relieve pain. Occasionally, the lifting of a crust or the removal of hard or desiccated skin helps demarcation or releases pus and relieves pain. Antibiotics Administration of pressured oxygen Amputation
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Wet, Dry, and Gas Wet Dry Gas
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Infection of Individ...
Surgical Site Infection
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