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Skin and Soft Tissue Infections: Operative approach

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A presentation designed for in hospital teaching

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Skin and Soft Tissue Infections: Operative approach

  1. 1. The operative approach
  2. 2.  Simple focal infections  Impetigo contagiosa – minor skin abrasion – normally caused by S aureus or S pyogenes  Folliculitis – staphylococcal pyodermas of the hair follicles which may coalesce to form carbuncles  Necrotising focal infections  Bacterial synergistic gangrene – can be wet or gas gangrene  Fournier’s gangrene (located in the scrotum or perineum) – this is a location-specific form of necrotising fasciitis  Toxic non-necrotising focal infections  Staph scaled skin syndrome  Toxic shock syndrome Ref for the following slides: Stevens, D.L., et al., Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infections diseases society of America. CID, 2014. 59: p. 10-50.
  3. 3.  Diffuse non-necrotising infection  Cellulitis and erysipelas  Diffuse necrotising cellulitis  Pyomyositis  Abscesses
  4. 4.  Simple abscesses  Incision to known area of abscess  Along langer’s lines where possible  Remove all infected tissue  Generally not for primary closure  Complex infections such as carbuncles  Excise whole area of infection  Some evidence that skin grafts can be done primarily however this is not common practice  Post-operative antibiotics do not affect wound healing but may reduce rates of recurrence in simple abscesses and carbuncles
  5. 5.  Most breast abscesses develop as a complication of lactational mastitis  I&D yields lower recurrence rate BUT results in  scarring,  structural damage,  risk of milk fistula,  painful breastfeeding,  prolonged healing times,  poor cosmesis  Therefore US guided needle aspiration +/- drain insertion is treatment of choice in most cases  Post acute infection, may be need for excision of damaged/chronically inflamed tissueRef:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3335354/pdf/brc-0007-0032.pdf http://iahealth.net/breast-abscess-and-mastitis/ BMJ Best Practice  Image redacted for uploaded edition  Please google breast abscesses to find your own!
  6. 6. Agostini, T., et al., Successful combined approach to a severe Fournier’s gangrene. Indian Journal of Plastic Surgery, 2014. 41(1): p. 132- 136. https://radiopaedia.org/articles/fournie r-gangrene https://www.researchgate.net/figure/Fo urniers-gangrene-of-the- scrotum_fig2_221915361 Recommended reading!! 
  7. 7.  Three concentric zones of erythema, cyanosis and necrosis at the site of synergistic infection  Often a small cut, bruise or abrasion as the initial trigger  Common skin bacteria with superimposed (synergistic) bacteria  C. perfringens creates gas gangrene  Treatment is multimodal  IVF  Vasopressors if required  Broad spectrum Abx covering gram positive and gram negative as well an anaerobic bacteria – e.g. vanc + tazocin or vanc meropenem or vanc + ceftriaxone + metronidazole or vanc + ciprofloxacin + metronidazole  Urgent debridement in theatre – down to underlying healthy tissue. Any plane that separates easily with blunt dissection should be considered involved  Delayed reconstruction
  8. 8.  Many skin and soft tissue infections can be managed conservatively  Antibiotic use is generally to cover common skin bacteria that have breached the skin immune barrier through minor trauma  US-guided needle aspiration can be used for breast abscesses  UNLESS the abscess is >5cm in which case I&D should be considered  Incision and drainage is the mainstay of treatment for skin abscesses  Excision is the mainstay of treatment for carbuncles  Antibiotics post-op help reduce risk of recurrence  Necrotising fasciitis and fournier’s are surgical emergencies requiring extensive debridement down to healthy tissue (sometimes amputation) as well as broad spectrum antibiotics and IVF and often vasopressor support

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