Soft-Tissue and Hand Infections


Chapter 21

Soft-Tissue and Hand Infections



Bites



1. Human bites


• Generally polymicrobial: Staphylococcus aureus, Streptococcus, Corynebacterium, Eikenella corrodens, and anaerobics


• Eikenella species unique to human bites


▪ Treat with penicillin including ampicillin and amoxicillin


▪ Eikenella species are resistant to clindamycin.


• Note that fight bites require operative exploration and washout because bacteria can be inoculated into joint spaces and spread proximally by extensor tendon motion.


2. Dog bites


• Immediately irrigate wounds with saline and wash with soap and/or Betadine


• Leave puncture wounds open to heal by secondary intent.


• Lacerations can be repaired after copious irrigation if wound appears clean.


• Penicillin antibiotics most commonly used


• Must be concerned about rabies


▪ If a known animal, it should be quarantined for at least 10 days.


▪ If an unknown animal, rabies prophylaxis is indicated.


○ Rabies prophylaxis


◆ If prior vaccination: Wash wound thoroughly and provide booster vaccine.


◆ If no prior vaccination: Wash wound thoroughly, administer rabies vaccine and rabies immunoglobulin.


3. Cat bites


• Cat bites tend to result in puncture wounds that can seal quickly; therefore, incision and drainage is recommended.


• High rate of infection from cat bites


• Many infections are polymicrobial; however, Pasteurella multocida is unique to cat bites.


▪ Pasteurella is resistant to cephalexin and cefazolin.


▪ Treat with amoxicillin-clavulanate or fluoroquinolone and clindamycin for penicillin-allergic patients.


▪ Preferred treatment for pediatric patients is trimethoprim-sulfamethoxazole (Bactrim) and clindamycin.


4. Snake bites


• The majority of snakebites are from pit vipers.


• Treat with immediate immobilization to prevent spread of venom, tetanus prophylaxis, broad-spectrum antibiotics, and observation for venom inoculation (worsening edema, pain, ecchymosis, altered mental status, coagulopathy, compartment syndrome).


• Antivenin is indicated for progressive injury or symptoms.


▪ If nonurgent, skin test first for hypersensitivity reaction is preferred.


• Avoid debridement and/or tourniquet application


5. Spider bites


• Brown recluse spider


▪ Venom inoculation causes a dermonecrotic reaction: Blistering, ischemia, ulceration at the bite site.


▪ Treat with Dapsone.


○ Watch for hematologic side effects.


• Black widow spider


▪ Venom is a neurotoxin that causes severe muscle pain and cramping. Late findings include abdominal pain, tremors, emesis, excessive salivation, and shock.


▪ Treat with calcium gluconate and benzodiazepines (e.g., diazepam).


▪ Spider antivenin can be used in immunocompromised patients.


6. Scorpion stings


• Stings are typically self-limiting in adults.


• Symptoms include severe localized pain and hyperesthesia and can progress to blurry vision, strabismus, dyspnea, dysphagia, incontinence, fevers, and muscle contraction.


• Treat initially with cold compresses and observation.


• In children, symptoms can be more severe.


▪ Treat with admission, monitoring, and potentially intubation for airway protection.


• Avoid debridement and tourniquet application.


7. Special considerations


• Tetanus prophylaxis


▪ If prior vaccination


○ Tetanus-prone wound (contaminated, etc.): Administer tetanus booster if last dose occurred more than 5 years before new injury.


○ Non-tetanus-prone wound (clean): Administer tetanus booster if last dose occurred more than 10 years from new injury.


▪ If no prior vaccination


○ Tetanus immunoglobulin



Necrotizing Soft-Tissue Infections



1. Necrotizing fasciitis: A progressive soft-tissue infection affecting skin, subcutaneous tissue, and fascia and sparing muscle


• Extremely high mortality and rapid progression


• Can result from minor trauma or hematogenous spread


▪ Most patients have predisposing morbidity, placing them at risk.


○ Immunocompromised


○ Diabetes


○ Renal failure


○ Substance abuse


▪ Head and neck infections can result from pharyngeal abscesses, tonsillar abscesses, and dental abscesses.


• Requires emergent debridement of all devitalized tissue


2. Classification


• Type 1 (75% of cases): Polymicrobial, mixed aerobic and anaerobic infections (non-group-A Streptococcus)


▪ Treat with ampicillin-sulbactam, clindamycin, ciprofloxacin, or gentamicin.


• Type 2: Monomicrobial, group-A Streptococcus (Streptococcus pyogenes)


▪ Treat with clindamycin and penicillin.


3. Progression of infection


• Initial cellulitis stage: Tenderness, erythema, edema, warm skin, fever


▪ May have increased white blood cells (WBCs), thrombocytopenia, hyperkalemia


• Cellulitis progresses to ischemia with severe pain, crepitus, and bullae formation.


• Final stage characterized by frank necrosis, anesthesia, and “dishwater” drainage.


4. Principles of management


• Fluid resuscitation


• Intravenous antibiotics


• Emergent surgical debridement


▪ Include fasciotomies in setting of compartment syndrome.


▪ Many require multiple trips to the operating room for serial debridement.


• Hyperbaric oxygen is indicated as an adjunct to surgical debridement for patients with persistent or extensive necrosis.


• Negative pressure wound therapy (NPWT) is often used as a bridge to reconstruction after debridement.


5. Fournier’s gangrene


• A necrotizing soft-tissue infection of the perineum


• Risk factors: Diabetes, alcoholism, smoking, leukemia, immunocompromised


• Rapid progression and high mortality


• Treat as above and include antibiotic coverage for anaerobic clostridium species.



Other Common Soft-Tissue Infections



1. Methicillin-resistant Staphylococcus aureus (MRSA)


• Increasingly common flora, especially in the nares


• More virulent and resistant to penicillins and cephalosporins


• Suspect in patient with persistent infection in setting of penicillin antibiotic treatment.


▪ Treat with vancomycin, linezolid, trimethoprim-sulfamethoxazole (Bactrim), or clindamycin.


• Nasal mupirocin (Bactroban) can be used to decolonize patients who are noted to be carriers by nasal culture.


2. Orbital cellulitis


• Signs


▪ Edema of the upper and lower eyelids


▪ Erythema and cellulitis in the periorbital region


▪ Proptosis


▪ Pain with globe movement


• Diagnosis: Computed tomography (CT) scan


• Treatment: Broad-spectrum intravenous antibiotics and operative drainage


3. Purpura fulminans


• Signs: Acute onset of hemorrhagic bullae formation, desquamation, bilateral symmetric gangrene, and shock


• Rapid progression, with high mortality


▪ Most common pathogens are Neisseria meningitides and MRSA


• Typically involves pediatric patients


• Treatment: Supportive care, broad-spectrum intravenous antibiotics, and activated protein C


▪ Delay surgery until demarcation occurs, except in the setting of acute wound infection or compartment syndrome.


4. Hidradenitis suppurativa


• A defect of the follicular epithelium causing follicle occlusion, rupture, and formation of abscesses and sinus tracts, which leads to chronic apocrine gland inflammation and secondary bacterial infections


• Commonly affects hair-bearing regions with apocrine glands and skin folds (e.g., axilla, groin, perineum).


• Most common pathogens are Staphylococcus aureus and Streptococcus viridans.


• Treatment: Antibiotics and incision and drainage of acute abscesses followed by wide excision of all involved skin and sinus tracts with healing by secondary intent or grafting


5. Toxic shock syndrome


• Signs: Fever, hypotension, diffuse macular rash, and desquamation of the palms and soles 2 weeks after onset of symptoms


• Can occur after surgery, trauma, or retained foreign bodies (e.g., nasal packing, tampons, etc.)


• Most common pathogens are Staphylococcus aureus and group-A Streptococcus pyogenes.


▪ Streptococcal toxic shock syndrome characterized by severe disproportionate pain, with potential progression to coagulopathy and organ failure


• Treatment: Supportive care and antibiotics


6. Wound infections


• Can develop after surgery, trauma, injury


• Risk factors can include host (diabetes, malnutrition, obesity, ischemia, steroid use, immunosuppression), wound (presence of nonviable tissue, foreign bodies, contamination), and procedural (length of operation) characteristics.


▪ Of the wound factors, contamination portends the highest risk.


• Treatment: Drainage and/or debridement, antibiotics, supportive care

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Sep 2, 2016 | Posted by in Aesthetic plastic surgery | Comments Off on Soft-Tissue and Hand Infections

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