Skin and Soft Tissue Infections – Incision, Drainage, and Debridement
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Skin and soft-tissue infections (SSTIs), which include infections of skin, subcutaneous tissue, fascia, and muscle, encompass a wide spectrum of clinical presentations, ranging from simple cellulitis to rapidly progressive necrotizing fasciitis. Diagnosing the exact extent of the disease is critical for successful management of a patient of soft-tissue infection. [1, 2, 3, 4, 5]
The various types of SSTIs, listed according to clinical presentation and anatomic location, include the following:
Furuncles
Carbuncles
Necrotizing fasciitis, also known as hemolytic streptococcal gangrene, Meleney ulcer, synergistic gangrene, and Fournier gangrene (when localized to the scrotum and perineal area)
Pyomyositis
SSTIs may be caused by any of a formidable number of pathogenic microorganisms, and they may be either monomicrobial or polymicrobial. The following are the most important pathogens:
Staphylococcus aureus (the most common pathogen)
Streptococcus pyogenes
Site-specific infections – Indigenous organisms (eg, gram-negative bacilli in perianal abscesses)
Immunocompromised hosts and complicated SSTIs – Multiple organisms or uncommon organisms (eg, Pseudomonas aeruginosa, beta-hemolytic streptococci, Enterococcus)
Polymicrobial necrotizing fasciitis – Mixed infection with both aerobes (eg, streptococci, staphylococci, or aerobic gram-negative bacilli) and anaerobes (eg, Peptostreptococcus, Bacteroides, or Clostridium)
Monomicrobial necrotizing fasciitis: S pyogenes
For the purposes of this article, SSTI may be divided into the following categories:
Uncomplicated SSTI
Nonnecrotizing complicated SSTI
Necrotizing fasciitis
Uncomplicated SSTIs include superficial cellulitis, folliculitis, furunculosis, simple abscesses, and minor wound infections. These infections respond well to either source control management (ie, drainage or debridement) or a simple course of antibiotics. These infections pose little risk to life and limb.
Complicated SSTIs involve the invasion of deeper tissues and typically require significant surgical intervention. The response to therapy is often complicated by underlying disease states. Complicated SSTIs include complicated abscesses, infected burn wounds, infected ulcers, infections in diabetics, and deep-space wound infections. They are often limb- or life-threatening.
Necrotizing fasciitis is a progressive, rapidly spreading, inflammatory infection that is located in the deep fascia and is associated with secondary necrosis of the subcutaneous tissues. The inflammation of the deep fascia causes thrombosis of the dermal vessels, and it is this thrombosis that is responsible for the secondary necrosis of the overlying subcutaneous tissue and skin.
It is imperative to distinguish necrotizing infections from nonnecrotizing infections. Early diagnosis and intervention may save a life; delayed diagnosis and treatment may lead to loss of a limb or a life.
Factors predisposing to the development of SSTIs include the following:
Breach in the epidermis
Dry and irritated skin
Immunocompromised status – Malnutrition, hypoproteinemia, burns, diabetes mellitus, AIDS
Chronic venous insufficiency
Chronic lymphatic insufficiency
Chronic neuropathy
Any abscess, however small, must be drained for complete resolution. Any ulcer covered with dead and necrotic tissue must be debrided to promote growth of healthy granulation tissue and healing. Necrotizing fasciitis is a surgical emergency; early surgical treatment optimizes outcomes for these patients.
There are no absolute contraindications for incision, drainage, and debridement of SSTIs. If the patient’s physical condition is compromised, stabilization to render him or her fit for anesthesia should be carried out before these procedures are undertaken.
In the drainage of an abscess, the incision should be made at the point of maximal fluctuance. If possible, it should be made in a dependent area; however, a dependent incision should not be made if a tubercular etiology is suspected. Ideally, the direction of the incision should be in line with the natural skin crease.
A bold incision must be made that goes all the way into the abscess cavity. However, if there are any major vessels or nerves in the area, additional care should be taken in making the incision, and blunt dissection should be used instead to enter the abscess cavity. Any necrosed or unhealthy skin on the roof of the abscess should be excised completely.
Debridement should be done until healthy dermal bleeding is seen on the edges of the skin. There should be no loose undermined skin edges at the end of surgical debridement. However, overzealous debridement should be avoided in nonnecrotizing SSTIs; a staged debridement should be planned to minimize damage to healthy tissue.
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[Guideline] Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america. Clin Infect Dis. 2014 Jul 15. 59(2):e10-52. [Medline]. [Full Text].
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Hemant Singhal, MD, MBBS, MBA, FRCS(Edin), FRCS, FRCSC Consultant Breast Surgeon, Clementine Churchill Hospital; Director of Breast Service, Medanta The Medicity; Senior Lecturer, Department of Surgery, Imperial College School of Medicine
Hemant Singhal, MD, MBBS, MBA, FRCS(Edin), FRCS, FRCSC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada, Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.
Kanchan Kaur, MBBS, MS (GenSurg), MRCSEd Consulting Breast and Oncoplastic Surgeon, Medanta, The Medicity, India
Disclosure: Nothing to disclose.
Regina A Bailey, MD, JD, LLM Resident Physician, Department of Emergency Medicine, Baylor College of Medicine
Regina A Bailey, MD, JD, LLM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, Society for Academic Emergency Medicine, Emergency Medicine Residents’ Association, American Bar Association
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Erik D Schraga, MD Staff Physician, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates
Disclosure: Nothing to disclose.
Skin and Soft Tissue Infections – Incision, Drainage, and Debridement
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