Soft Tissue Infections

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Slide 1 : Soft Tissue Infections
Slide 2 : Abscess
Slide 3 : Abscess An ABSCESS is localised collection of pus in the body. Pus is composed of neutrophils, exudate and bacteria
Slide 4 :
Slide 5 : The result of “skin popping” -Multiple injection site abscesses
Slide 6 : Causative Organisms Staphylococcal organisms(most common staphylococcus aureus) Streptococcal organisms Gram Negative Bacteria E. coli Pseudomonas Klebsiella Anaerobes
Slide 7 : Types Pyogenic Abscess Pyaemic Abscess Metastatic Abscess Cold Abscess
Slide 8 : Pyogenic Abscess
Slide 9 : Causes Direct infection from outside due to penetrating wound Local extension from adjacent focus of infection Lymphatics Blood stream or Haematogenous spread
Slide 10 : PATHOLOGY
Slide 11 :
Slide 12 : 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
Slide 13 : 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
Slide 14 : Investigations All routine Examinations USG abdomen CXR CT Scan Specific Tests
Slide 15 : 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
Slide 16 : Drainage of PUS Free or liberal incision Hilton’s method Particularly in places like Neck Axilla & Groin
Slide 17 :
Slide 18 : 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
Slide 19 : Characterstic Features They are multiple They are deep seated Tenderness is minimal No local rise in temperature “It is also called nonreactive abscess”
Slide 20 : 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
Slide 21 : 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.
Slide 22 : Causes Tuberculosis Actinomycosis Leprosy Madura foot
Slide 23 : 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
Slide 24 : Clinical features No local rise in temperature No tenderness No redness Soft cystic and fluctuant swelling Transillumination is negative
Slide 25 : 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
Slide 26 : Erysipelas
Slide 27 : Definition A sharply demarcated streptococcal infection of the superficial lymphatic vessels, associated with broken skin on the face More superficial than cellulitis
Slide 28 : Etiology • Typically caused by Group A ß-hemolytic Streptococcus
Slide 29 : Sites Orbit Face Scrotum Umbilicus in Infants
Slide 30 : Clinical Features Intense erythema, Induration Sharply demarcated borders (differentiates it from other skin infections) Discharge is serous
Slide 31 :
Slide 32 : Milian’s Ear Sign Skin of ear lobule can be involved in Erysipelas Will not be involved in Cellulitis
Slide 33 : Complication Septicemia Localized cutaneous and subcutaneous gangrene Lymphedema of face and eyelid
Slide 34 : Treatment Penicillin or first generation cephalosporin (e.G. Cefazolin or cephalexin)
Slide 35 :
Slide 36 : Carbuncle & Furuncle deeper infections of the hair follicle that extend into the subcutaneous tissue
Slide 37 : 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.
Slide 38 : Predisposing Factors Increased friction and perspiration (obese individuals or athletes), Corticosteroid use, Diabetes mellitus, Inherited or acquired defects in neutrophil function
Slide 39 : 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.
Slide 40 : Carbuncle deep cutaneous infection involving multiple hair follicles characterized by destruction of fibrous tissue septa and formation of a series of interconnected abscesses.
Slide 41 : 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.
Slide 42 : 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
Slide 43 :
Slide 44 : Cellulitis
Slide 45 : Definition Cellulitis is a non suppurative spreading inflammation of subcutaneous tissue.
Slide 46 : Sources of infection Injuries—major or minor Surgical incision Wound or scratch Snake bite,scorpion bite,etc
Slide 47 : Etiology Skin flora most common organisms S. Aureus, 13-hemolytic streptococcus Immunocompromised gram-negative rods and fungi
Slide 48 : Precipitating factors Diabetes Low immunity
Slide 49 : Common sites Lower limbs Face Scrotum Forearm
Slide 50 : Pathophysiology
Slide 51 : 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.
Slide 52 :
Slide 53 :
Slide 54 :
Slide 55 : Different from Abscess Bcz………. No edge(diffuse swelling) No limit No pus No fluctuation “If untreated suppuration,sloughing and gangrene can occur”
Slide 56 : Complications Abscess Necrotising fascitis Toxaemia & Septicaemia Cellulitis can precipitate ketoacidosis in diabetics
Slide 57 : Cellulitis with Abscess Features: Cellulitis present Swollen Soft center, feels like fluid underneath Painful Tender
Slide 58 : 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)
Slide 59 : 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
Slide 60 : Treatment…. Outline area of erythema to monitor success of treatment Immobilize and splint (hands)
Slide 61 : Necrotising Fascitis
Slide 62 : Background An insidiously advancing soft tissue infection. Widespread fascial necrosis. Polymicrobial Most closely linked group A beta-hemolytic. Most cases caused by other bacteria
Slide 63 : 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.
Slide 64 : 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.
Slide 65 : 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.
Slide 66 : Pathophysiology
Slide 67 : Morbidity and Mortality Mortality rate as high as 25%. Cases with sepsis and renal failure have a mortality rate as high as 70%.
Slide 68 : 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.
Slide 69 : 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.
Slide 70 : 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.
Slide 71 : 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.
Slide 72 : 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
Slide 73 : Features Suggesting It Rapid progression Poor therapeutic response Blistering necrosis Cyanosis Extreme tenderness High temperatures, tachycardia, hypotension, altered mental status.
Slide 74 : Laboratory Cannot be relied upon. May facilitate diagnosis, but clinical is more important. WBC>14000, BUN> 15, Na < 135.
Slide 75 : Radiology Standard x-rays of little use. CT more sensitive. MRI and CT can delineate and determine extent of surgical resection.
Slide 76 : Medical Therapy Treat without delay Team approach ICU admission Monitor hemodynamics Antibiotics- combination or single Hyperbaric oxygen
Slide 77 : Antibiotics Combination: cover G- and G+ and anaerobes Ampicillin, gentamycin, Metronidazole Single coverage Imipenem covers aerobes, pseudomonas. Vancomycin for methicillin resistant staph.
Slide 78 : 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
Slide 79 : Complications Sepsis and renal failure Metastatic cutaneous plaques Systemic toxicity and death Loss of limb, deformities, psychosocial issues Medical/legal issues.
Slide 80 : Examples
Slide 81 :
Slide 82 :
Slide 83 : Gangrene
Slide 84 : 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
Slide 85 : Types and Where Dry Gangrene Wet Gangrene Gas Gangrene Necrotizing Fasciitis
Slide 86 : Dry Gangrene Affects bodies extremities
Slide 87 : Wet Gangrene
Slide 88 : 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
Slide 89 : Symtoms
Slide 90 : Sites legs (most common) Feet Toes Fingers limbs Internal organs
Slide 91 : 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
Slide 92 : Wet, Dry, and Gas Wet Dry Gas

 


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