Soft tissue infection

History
A 48-year-old man with a history of alcoholism and
cirrhosis presents to the emergency department for
evaluation for severe left leg pain and fever. The
patient says that his symptoms began after he
scraped the lateral aspect of his knee at home 3 days
ago. During the past 2 days, he has had subjective
fever and noticed decreased urinary frequency. The
patient has self-medicated with aspirin for these
symptoms. He consumes approximately 16 oz (473
mL) of whiskey per day and smokes one pack of
cigarettes per day. On physical examination, his
temperature is 39.2 C (102.6 F), pulse rate is 110
beats/ minute, blood pressure is 115/ 78 mm Hg, and
respiratory rate is 28 breaths/ minute. His skin is
mildly icteric.

History
The findings from his cardiopulmonary examination
are unremarkable. The abdomen is soft and without
hepatosplenomegaly or ascites. The left leg is
edematous from the ankle to the upper thigh. The
skin is tense and exquisitely tender; however, it is
without erythema, fluctuance, necrosis, or vesicular
changes. Examination of the right leg reveals
normal findings. Laboratory studies demonstrate a
WBC count of 26,000/ mm3 and normal hemoglobin
and hematocrit values. Other laboratory studies
reveal sodium 128 mEq/ L, glucose 180 mg/ dL, total
bilirubin 3.8 mg/ dL, and direct bilirubin 1.5 mg/ dL.
Radiographs of the left leg reveal no bony injuries
and no evidence of air in the soft tissue space.

Questions

What is the most likely diagnosis?

What is the best therapy for this condition?

Summary

A 48-year-old man with alcoholism and cirrhosis

presents with a severe soft tissue infection
following a seemingly trivial trauma to his left
lower extremity.
Most likely diagnosis: Severe soft tissue infection
of the left lower extremity.
Best therapy: Antimicrobial therapy, imaging to
determine the nature and extent of the soft
tissue infection, and possible surgical drainage
and/ or debridement if indicated (based on
imaging results).

Considerations
This patient with alcoholic cirrhosis presents with
severe soft tissue infection of the left lower
extremity following a trivial soft tissue injury 3
days ago. His vital signs and laboratory studies
(fever, tachycardia, tachypnea, high WBC count,
and low sodium) indicate that he is already
septic. An individual with alcohol-induced
cirrhosis is considered immune compromised,
and has increased susceptibility to multiple types
of infections and septicemia. Blood cultures
should be obtained promptly, followed by the
initiation of intravenous fluids and empiric
antibiotic therapy to cover potential polymicrobial
infections.

Considerations
In this patients case, vancomycin and
piperacillin/ tazobactam are an appropriate initial
treatment regimen. Next, a CT scan of the
affected lower extremity should be obtained to
evaluate the possibility of deep tissue space
infections and to assess the extent of the soft
tissue infection. Although his history is
suggestive of a skin-based soft tissue infection,
the findings on his affected extremity are not
specific for a necrotizing soft tissue infection
(NSTI) and may be compatible with a deepseated abscess with extensive adjacent soft
tissue infection.

Considerations
A CT scan is valuable to guide the extent of the
wound exploration/ debridement and help identify
potential hidden abscesses. Surgical debridement
and/ or wide drainage are very important adjuncts in
this patients treatment, and delays in surgical
treatment have been demonstrated to negatively
affect the outcomes of patients with NSTIs. It is
important to collect tissue and fluid specimens for
culture and Gram Stain to optimize the antibiotic
treatment. Distant end-organ dysfunction including
acute respiratory insufficiency, acute liver
dysfunction, and acute kidney injuries can occur in
individuals with NSTI, and close monitoring is needed
for prompt implementation of supportive care..

Considerations
The surgical approach should begin with incision and
inspection of the soft tissue space and fascia. Easy
separation of the subcutaneous tissue from the
underlying fascia indicates microvascular thrombosis
and necrosis and should be treated with soft tissue
debridement. The deep fascia overlying the muscle
should be inspected for viability, and if discoloration
and necrosis is encountered, debridement of the
fascia should be carried out. Muscle fascia is a
natural protective layer for the muscles, and
infections deep to the fascia occur uncommonly
unless a deep puncture wound with bacterial
inoculation into the muscle has occurred.

Considerations
Because of the rich blood supple to the skin, patients with
NSTI generally do not develop skin necrosis and bullous
changes until late in the disease process. The absence of skin
abnormalities is one of the leading factors contributing to
delays in recognition of NSTI. When the process is recognized,
all necrotic tissue should be excised. Infectious involvement
of the muscles is uncommon except with deep puncture
wounds into the muscles and in cases of infections involving
Clostridium species. When patients with NSTI fail to improve
with supportive care, antibiotic therapy, and surgical
debridement, consideration should be given that not all
affected soft tissue has been identified and debrided. The
lack of improvement in patients is often due to inadequate
debridement and/ or inappropriate antibiotic selection
(source control).

SKIN AND SOFT TISSUE INFECTIONS

SKIN AND SOFT TISSUE INFECTIONS

DEFINITIONS
SIMPLE CELLUTITIS: Milder form of soft tissue infection
without microvascular thrombosis and necrosis. Clinically,
patients do not exhibit systemic signs and symptoms.
Antibiotics therapy are sufficient treatment.
NECROTIZING CELLULITIS: This term refers to skin and
superficial subcutaneous fat infection associated with
microvascular thrombosis and necrosis. The patient often
exhibits systemic signs and symptoms. This process is
generally related to infection with group B streptococcus or
community-acquired MRSA. Treatment consists of
antibiotics, local debridement, and supportive care.
NECROTIZING FASCIITIS: This term refers to infection of the
skin, subcutaneous fat, and fascia. This process is
frequently associated with microvascular thrombosis and
tissue necrosis. Soft tissue debridement is an essential
component of treatment.

DEFINITIONS
FINGER TEST FOR NSTI DIAGNOSIS: This is an adjunct method of
diagnosing NSTI. A 2- to 3-cm skin incision is made under local
anesthesia and carried down to the fascia. This is then followed by
insertion of gloved finger to digitally evaluate the fascia. With NSTI, the
subcutaneous fat will separate easily without bleeding, and there will
often be a presence of murky dishwater fluid in the subcutaneous
tissue.
IMMUNE-DEFICIENT HOSTS WITH NSTI: Immune-deficient hosts include
individuals with who use corticosteroids, with active malignancy,
receiving chemotherapy or radiation therapy, with positive HIV status,
receiving immunosuppressive medications for bone marrow or solid
organ transplantation, with cirrhosis, and with alcoholism. Studies have
shown that immunocompromised hosts do not exhibit the usual
responses to NSTI, and therefore, are susceptible to delayed treatments
and misdiagnoses. Increasing vigilance for this condition in susceptible
individuals is important.
NSTI ASSOCIATED WITH SURGICAL SITES: Occasionally, this can occur
and can be difficult to diagnose and differentiate from simple wound
infections. The systemic signs associated with this process are often
easily attributed to other conditions, such as pneumonia or atelectasis.

DEFINITIONS
COMMUNITY ACQUIRED-MRSA INFECTION (CA-MRSA): These
infections are becoming increasingly more common. CAMRSAs are genetically and phenotypically different from
hospital-acquired MRSA. CA-MRSA may produce the
pathogenic Panton-Valentine leucocidin (PVL) toxin, which
destroys white blood cells. Oral antibiotic options for CAMRSA include clindamycin, trimethoprim-sulfamethoxazole,
tigecycline, doxycycline, minocycline, linezolid, or
daptomycin.
TETANUS IMMUNIZATION: Tetanus is the clinical sequelae
associated with Clostridium tetani infections. Individuals
residing in the United States are given a set of initial
immunization shots during infancy, childhood, and
adolescence. Booster shots are recommended every ten
years for adults. Clostridium tetani is an organism that can be
found in soil, dust, and animal feces, and in high-risk wounds
include animal bites, human bites, and dirty wounds

DEFINITIONS
TETANUS IMMUNE GLOBULIN: This is an IgG
antibody that neutralizes the toxins that would
cause tetanus. Administration provides
transient passive immunity for individuals who
are not properly immunized (or have unknown
tetanus immunization history) and have been
exposed to or suspected of having been
exposed to the tetanus toxin.

CLINICAL APPROACH
Soft tissue infections should be suspected in individuals with
pain and edema involving the skin, an extremity, or a body
region, which may or may not be associated with
inflammatory changes in the skin. It is important to elicit a
detailed history from the patient regarding recent trauma to
the affected area, including trivial trauma such as skin
abrasions and minor lacerations. Severe soft tissue
infections should be suspected when individuals described
above exhibit systemic signs such as tachycardia, fever,
tachypnea, hypotension, or oliguria.
Physical examination of the affected soft tissue area can be
extremely helpful. Pain out of proportion to skin changes is a
highly suspicious finding, and is often thought to be related
to microvascular thrombosis and tissue ischemia associated
with NSTI. It is extremely important to pay attention to the
patients descriptions of symptoms and not disregard their
complaints due to absence of specific skin changes.

CLINICAL APPROACH
Laboratory studies are helpful in identifying patients with
NSTI and may be helpful for disease severity stratification.
WBC count over 20,000 mm3 and hyponatremia (serum
sodium < 130 mEq/ L) have been reported to prognosticate
poor outcomes.
For patients with possible NSTI, deep abscesses, and
unclear extent of their infectious processes, a CT scan can
be very helpful to identify fat stranding, fluid and/ or gas
collections tracking along fascial planes, which are early
signs of NSTI. In addition, CT scans can identify deep soft
tissue abscess that clinically may present as a simple soft
tissue infection. CT imaging have been reported to be
associated with 100% sensitivity and 81% specificity for
NSTI diagnosis. Visualization of the subcutaneous tissue
and fascia are important during surgical exploration for
NSTI.
T

CLINICAL APPROACH
The finger test helps to identify tissue necrosis
along the fascia. In addition, the findings of
marked subcutaneous tissue edema and dishwater-appearing fluid in the subcutaneous
space are highly suggestive of NSTI.
Close monitoring of patients following the initial
wound exploration and/ or soft tissue
debridement is vital, because if the patients do
not show improvements, re-exploration and/ or
modification of antibiotic treatments should be
implemented.

CLINICAL MANIFESTATIONS OF NECROTIZING SOFT TISSUE

INFECTION

Group A -Hemolytic Streptococcus Soft

Tissue Infection
This type of infection has been referred to in the lay press as
the flesh-eating bacterial infection. This form of NTSI
frequently affects individuals with immune compromised
conditions (alcoholic, diabetic, and malnourished patients).
Surprisingly, these infections can also affect healthy
individuals following trivial soft tissue trauma such as skin
abrasions. Approximately, 75% of these infections are
community acquired. Bacteremia and toxic shock syndrome
are associated with these infections in about 50% of the cases.
The local process usually spreads rapidly over hours to days.
The combination of clindamycin and penicillin has been touted
to produce superior results compared to penicillins alone.
There is limited evidence suggesting that adjunctive treatment
with intravenous immunoglobulins (IVIG) will help neutralize
the bacteria-produced superantigens and improve outcomes.

Toxic Shock Syndrome (TSS)

TSS is a clinical syndrome caused by pyrogenic toxin
superantigens produced by certain communityacquired MRSA species and Group A -Hemolytic
Streptococcus species. The binding of the
superantigens to major histocompatibility complex
class III molecules lead to T-cell clonal expansion and
massive release of proinflammatory cytokines by
macrophages and T cells.
Patients with TSS frequently develop mental
obtundation, hyperdynamic shock, and multiple-organ
dysfunction syndrome (MODS). The systemic findings
of TSS frequently do not correlate with the local extent
of the soft tissue or pelvic (vaginal) infections and thus
can cause delays in diagnosis and treatment.

Fourniers Gangrene
This is a rapidly progressive soft tissue infection of
the perineal, scrotal, and penis area in males, but
the process can occur less commonly in the perineal
region in females. The infection can lead to skin
necrosis, sepsis, and death within hours to days if
unrecognized and untreated. Fourniers gangrene
was originally described in 1883 as scrotal soft
tissue infections in a group of healthy young men.
The infection is commonly a polymicrobial
synergistic type of infection leading to sepsis and
MODS. Treatment consists of broad-spectrum
antibiotics directed at aerobic and anaerobic
organisms and radical debridement of the affected
soft tissue.

Review questions

1. Which of the following statements is true regarding

NSTI treatment in immune-compromised hosts?

A. Antibiotic therapy is not effective treatment for these
B.
C.
D.

E.

individuals
The outcome of NSTI treatments in immune-compromised
hosts is the same as in healthy normal hosts
NSTI in immune-compromised hosts usually is caused by
different bacterial organisms from the usual population
Clinical presentations of NSTI is the same for immune
compromised individuals and immune competent
individuals
Treatment is often delayed in immune compromised hosts
because of variability in clinical presentation.

E. Observational studies suggest that

immunocompromised patients with NSTI had
delays in diagnosis and surgical treatment,
because many of the patients failed to exhibit
the usual clinical signs and did not have the
usual WBC responses associated with NSTIs.
Clinicians need to maintain a higher level of
vigilance, consider additional imaging studies,
and earlier surgical evaluations.

Review questions
2. Which of the following is most accurate for

the diagnosis of NSTI?

A. CT scan
B. History and physical examination
C. Blood and skin swab culture
D. Serology
E. Clinical experience

A. CT scan is highly sensitive and specific for

the diagnosis of NSTI. The reported sensitivity
is 100%, specificity of 85%, positive predictive
value of 76%, and negative predictive value
of 100%; therefore, the CT scan is an
excellent tool to rule-out NSTI.

Review questions
3. Which of the following soft tissue infection

processes can be treated with antibiotics

alone?
A. Superficial abscess
B. Necrotizing cellulitis
C. Deep muscle infection following hip

prosthesis implantation
D. Necrotizing myositis
E. Impetigo

E. Impetigo is a common skin infection with small

pustules that develop along with soft tissue
inflammation. This process is nearly always
caused by -hemolytic streptococcus infections or
Staphylococcus aureus. Treatment is antimicrobial
therapy and skin care. The superficial abscess
requires drainage, necrotizing cellulitis requires
debridement, deep muscle infection following hip
prosthesis placement will require surgical
drainage and possibly removal of hardware.
Necrotizing myositis will require debridement.

Review questions
4. A 38-year-old man with a history of injection heroin abuse

presents to the emergency center with tenderness and swelling

that extends circumferentially around his left upper arm. The
entire area is minimally erythematous, but it is tense and
swollen. The patient indicates that he had injected some black
tar heroin into the area 6 days ago. His temperature is 39.5 C
(103 F), heart rate is 125 beats/ minute, and WBC is 46,000
mm3. CT scan of the arm reveals no evidence of abscess or
venous thrombosis, but there is extensive tissue stranding along
the muscle fascia and in the muscles. Which of the following is
the most appropriate treatment?
A. Admit to the hospital for IV antibiotics, and if he does not improve
B.
C.
D.
E.

then repeat the CT to look for an abscess

Perform radical debridement of the affected area followed by
intravenous antibiotics therapy
Perform a transesophageal echocardiography to look for
endocarditis and treat patient with IV antibiotics
Admit the patient for antibiotics treatment and hyperbaric oxygen
treatment
Perform radical debridement of the affected area.

B. This patient has findings consistent with

NSTI associated with injectional drug abuse.
Based on the history of black-tar heroin
injection, the infection is likely a polymicrobial
synergistic infection. Early, aggressive
surgical debridement and broad-spectrum
antimicrobial therapy are the keys to reduce
mortality associated with this process. The
role of hyperbaric treatment in this population
is unclear.

Review questions
5. A 33-year-old house painter sustained an abrasion and

superficial laceration of the left shoulder 2 days ago. He

presents to the outpatient clinic with an area of erythema
extending 3 cm along the area of skin abrasion and
superficial laceration. There is an area of fluctuance
underneath the skin, and the tenderness does not appear
to extend beyond the area. His temperature and vital
signs are normal. Which of the following is the most
appropriate treatment?
A. Oral antibiotics for 3 days followed by reassurance. Perform
B.
C.
D.
E.

incision and drainage if it does not improve

Topical antibiotic ointment application and dressing
changes
Oral antibiotics for 1 week
Incision and debridement of the area
Incision and drainage of the area, followed by 1-week
course of oral antibiotics.

E. The descriptions given are consistent with a

soft tissue abscess with a 3-cm rim of
surrounding cellulitis. Incision and drainage of
the abscess with antibiotics treatment are the
most appropriate for this patient.

Review questions
6. A 62-year-old man with diabetes returns to the emergency

department 3 days after undergoing incision and drainage of

a perirectal abscess. The patient complains of fever and
malaise. Evaluation of the perirectal area reveals an open
draining wound with a 20-cm area of surrounding induration
and erythema, with some localized blistering of the skin. The
infection appears to have extended to involve his entire
perineum, scrotum, and the anterior abdomen. Which of the
following is most likely the process that is occurring?
A. A. Toxic shock syndrome
B. Clostridial gas gangrene
C. NSTI caused by group A -hemolytic streptococcus
D. Polymicrobial synergistic NSTI
E. Community-acquired MRSA

D. The origin of the infection in this patient is

the perirectal area. Abscesses that originate
in that location are most likely polymicrobial
in nature, and if left untreated, they can
progress to develop polymicrobial synergistic
NSTI. Hyperbaric treatment for NSTI has not
been shown to reduce mortality; in fact, there
is a general lack of strong clinical evidence to
apply hyperbaric treatments for NSTI, and
increase in hospital costs.

Review questions

7. A 55-year-old man with diabetes presents with a swollen, painful

right hand that developed 1 day after sustaining a puncture wound

to the hand while fishing in the Gulf of Mexico. His temperature is
39.5 C (103.1 F), pulse rate is 120 beats/ minute, and blood
pressure is 96/ 60 mm Hg. His right hand and forearm are swollen,
and a puncture wound with surrounding ecchymosis is present on
the hand. There is drainage of brown fluid from the wound. Which
of the following therapies is the most appropriate?
A. Supportive care, penicillin G, and hyperbaric treatment
B. Supportive care, penicillin G, tetracycline, ceftazidime, and surgical

debridement
C. Supportive care, penicillin G, tetracycline, ceftazidime, surgical
debridement, and hyperbaric treatment
D. Supportive care, penicillin G, clindamycin, and Intravenous Ig
E. Supportive care and penicillin G

B. This man developed a severe infection of the

hand and forearm following a puncture wound
to the hand that he sustained during a fishing
trip in the Gulf of Mexico. Because the
infectious organisms might be water-borne
bacteria, antimicrobial therapy needs to include
coverage for Vibrio species (Ceftazidime,
tetracycline), and at the same time penicillin G
should be included to cover for Gram positive
organisms. Incision and drainage are also very
important components of his treatment.

CLINICAL PEARLS
The most common findings in a patient with NSTI are
local edema and pain in the presence of systemic
signs such as high fever (hypothermia in some
patients), tachycardia, and often mental confusion.
NSTI should be suspected when pain and tenderness
extend beyond the area of skin erythema.
When NSTI is strongly suspected, exploration of the
wound through a limited incision may help to
establish the diagnosis. Drainage of dish water
fluid and easy separation of the subcutaneous tissue
from the affected fascia is seen during digital
exploration.

CLINICAL PEARLS

Rapid, aggressive surgical debridement is

the most important treatment for NSTI.
Lack of improvement after initial treatment
of NSTI may be related to inadequate
debridement and/ or inappropriate
antibiotic selection (lack of source control).