Necrotizing Soft Tissue Infections
Diabetics are more susceptible to skin and soft tissue infections, and in current studies, up to half of patients who develop necrotizing soft tissue infection have diabetes. Patients typically present with acute, severe illness and prominent skin finding
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Necrotizing Soft Tissue Infections J. Stone Doggett and Brian Wong
Précis Necrotizing soft tissue infections 1. Clinical setting: Up to half of the patients that develop necrotizing soft tissue infections have diabetes mellitus. Diabetics are more likely to present without the usual overt symptoms of necrotizing soft tissue disease. 2. Diagnosis: (a) History: Clinical findings include cellulitis that fails to respond to antibiotic treatment, pain out of proportion to the size of the lesion, the appearance of local anesthesia, bullous lesions, crepitus, and inflammation edema beyond the margin of the skin findings. Fever and leucocytosis are almost always present. (b) Imaging: Radiologic studies lack the necessary specificity in this disease to be very useful. That said, the preferred test is a non-contrast CT because it can be performed quickly. CT findings include vessel thrombosis, fluid tracking, perifacial air, skin thickening, lymphadenopathy, muscle edema, and fat stranding. (c) Management: Once the diagnosis is clear, aggressive surgical debridement and broad spectrum antibiotics must be initiated. Delayed “time to surgery” is consistently associated with increased morbidity and mortality. Without surgery, mortality approaches 100 %. Multiple debridements are usually required. Empiric antibiotic therapy should cover gram positive, gram negative, and anaerobic bacteria. Empiric antibiotic therapy should include clindamycin with either piperacillin-tazobactam or an antipseudomonal carbapenem. If MRSA is suspected, vancomycin or other antiMRSA antibiotic should be added. J.S. Doggett, M.D. • B. Wong, M.D. (*) Division of Infectious Disease, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd (NRC3), Portland, OR 97236, USA e-mail: [email protected] L. Loriaux (ed.), Endocrine Emergencies: Recognition and Treatment, Contemporary Endocrinology 74, DOI 10.1007/978-1-62703-697-9_4, © Springer Science+Business Media New York 2014
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J.S. Doggett and B. Wong
Necrotizing Soft Tissue Infection Necrotizing soft tissue infections have been divided into different clinical entities based on the microbiology, location, and degree of tissue involvement. Despite different classifications, all necrotizing soft tissue infections are medical emergencies that require early diagnosis, parenteral antibiotics, and aggressive surgical debridement to achieve optimal outcomes. The incidence of necrotizing soft tissue infection is estimated to be 0.04 cases per 1,000 person-years in the US. [1]. Diabetics are more susceptible to skin and soft tissue infections in general, and in current studies, up to half of patients who develop necrotizing soft tissue infection have diabetes [2, 3]. Diabetics are also more likely to present without overt symptoms indicative of a necrotizing infection. Because of this, physicians should consider necrotizing soft tissue infection in diabetics who present with skin infection and systemic signs of illness or progressive infection despite antibiotics. Necrotizing soft tissue infection
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