Skin and Soft Tissue Infections

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Skin and soft tissue infections are a common cause of hospitalization and use of antibiotic therapy, and may result in significant disability. Infections managed by surgeons may vary from simple, noncomplicated cellulitis to severe necrotizing soft tissue infections. The differentiation of necrotizing infections from nonnecrotizing infections is critical to achieving adequate surgical therapy. An understanding of the changing epidemiology of all complicated skin and soft tissue infections is required for selection of appropriate empiric antibiotic therapy.

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Terminology and definitions

A variety of terms are applied to infections of the skin and underlying soft tissue structures. For the purpose of therapeutic clinical trials, the Food and Drug Administration (FDA) uses the term “skin and skin structure infections.”1 The FDA specifically excludes necrotizing deep space infections from clinical trials, however, excluding infections involving the fascial planes and muscle and those infections with the greatest likelihood of adverse outcome.

Additionally, skin and skin structure

Nonnecrotizing skin and soft tissue infections

SSTI may occur with a wide variety of clinical presentations and in numerous clinical settings, with diverse etiologic processes, and with varying severities. Numerous bacteria may be involved in SSTI, with the likelihood of individual pathogens being altered by factors including the inciting disease process and the clinical presentation and setting. Most SSTI infections are generally mild to moderate in severity and include simple cellulitis, folliculitis, furunculosis, and minor

Necrotizing skin and soft tissue infections

NSTI are discussed separately because of (1) the increased severity; (2) the variation of pathogens relative to nonnecrotizing infections; (3) the difficulty and importance of establishing an early diagnosis; and (4) the impact of early, aggressive surgical debridement on outcome. NSTIs are serious infections, producing progressive tissue destruction with significant potential for soft tissue and limb loss and mortality. Despite advances in therapy over the past three decades, the mortality

References (99)

  • F.W. Endorf et al.

    The evolving characteristics and care of necrotizing soft-tissue infections

    Burns

    (2005)
  • B.W. Frazee et al.

    Community-acquired necrotizing soft tissue infections: a review of 122 cases presenting to a single emergency department over 12 years

    J Emerg Med

    (2008)
  • H.P. Freeman et al.

    Necrotizing fasciitis

    Am J Surg

    (1981)
  • J.A. Freischlag et al.

    Treatment of necrotizing soft tissue infections. the need for a new approach

    Am J Surg

    (1985)
  • J.A. Majeski et al.

    Early diagnosis, nutritional support, and immediate extensive debridement improve survival in necrotizing fasciitis

    Am J Surg

    (1983)
  • D.C. Vinh et al.

    Rapidly progressive soft tissue infections

    Lancet Infect Dis

    (2005)
  • J. Echols et al.

    Initial experience with a new system for the control and containment of fecal output for the protection of patients in a large burn center

    Chest

    (2004)
  • Guidance for Industry: Uncomplicated and complicated skin and skin structure infections: developing antimicrobial drugs...
  • D.L. Stevens et al.

    Practice guidelines for the diagnosis and management of skin and soft-tissue infections

    Clin Infect Dis

    (2005)
  • D.C. Elliott et al.

    Necrotizing soft tissue infections: risk factors for mortality and strategies for management

    Ann Surg

    (1996)
  • S. Deresinski

    Methicillin-resistant Staphylococcus aureus: an evolutionary, epidemiologic, and therapeutic odyssey

    Clin Infect Dis

    (2005)
  • S.K. Fridkin et al.

    Methicillin-resistant Staphylococcus aureus disease in three communities

    N Engl J Med

    (2005)
  • M.D. King et al.

    Emergence of community-acquired methicillin-resistant Staphylococcus aureus USA 300 clone as the predominant cause of skin and soft-tissue infections

    Ann Intern Med

    (2006)
  • G.J. Moran et al.

    Methicillin-resistant Staphylococcus aureus in community-acquired skin infections

    Emerg Infect Dis

    (2005)
  • T.S. Naimi et al.

    Comparison of community- and health care-associated methicillin-resistant Staphylococcus aureus infection

    JAMA

    (2003)
  • L.G. Miller et al.

    Necrotizing fasciitis caused by community-associated methicillin-resistant Staphylococcus aureus in Los Angeles

    N Engl J Med

    (2005)
  • M.N. Swartz

    Clinical practice. Cellulitis

    N Engl J Med

    (2004)
  • C.H. Wong et al.

    Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality

    J Bone Joint Surg Am

    (2003)
  • C.H. Wong et al.

    The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections

    Crit Care Med

    (2004)

  • Defining the group A streptococcal toxic shock syndrome. Rationale and consensus definition. The Working Group on Severe Streptococcal Infections

    JAMA

    (1993)
  • A. Dupuy et al.

    Risk factors for erysipelas of the leg (cellulitis): case-control study

    BMJ

    (1999)
  • J. Zimbelman et al.

    Improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection

    Pediatr Infect Dis J

    (1999)
  • D.L. Stevens et al.

    The Eagle effect revisited: efficacy of clindamycin, erythromycin, and penicillin in the treatment of streptococcal myositis

    J Infect Dis

    (1988)
  • P. Bernard et al.

    Roxithromycin versus penicillin in the treatment of erysipelas in adults: a comparative study

    Br J Dermatol

    (1992)
  • T.L. Bosshardt et al.

    Necrotizing soft-tissue infections

    Arch Surg

    (1996)
  • I. Brook et al.

    Aerobic and anaerobic bacteriology of wounds and cutaneous abscesses

    Arch Surg

    (1990)
  • D.L. Stevens et al.

    Linezolid versus vancomycin for the treatment of methicillin-resistant Staphylococcus aureus infections

    Clin Infect Dis

    (2002)
  • J. Weigelt et al.

    Linezolid versus vancomycin in treatment of complicated skin and soft tissue infections

    Antimicrobial Agents Chemother

    (2005)
  • D.L. Stevens et al.

    Successful treatment of staphylococcal toxic shock syndrome with linezolid: a case report and in vitro evaluation of the production of toxic shock syndrome toxin type 1 in the presence of antibiotics

    Clin Infect Dis

    (2006)
  • E.J. Ellis-Grosse et al.

    The efficacy and safety of tigecycline in the treatment of skin and skin-structure infections: results of 2 double-blind phase 3 comparison studies with vancomycin-aztreonam

    Clin Infect Dis

    (2005)
  • M. Raghavan et al.

    Newer treatment options for skin and soft tissue infections

    Drugs

    (2004)
  • J.P. Adant et al.

    Necrotizing fasciitis: a life-threatening infection

    Acta Chir Belg

    (1998)
  • M.F. Adinolfi et al.

    Severe systemic sepsis resulting from neglected perineal infections

    South Med J

    (1983)
  • D.A. Anaya et al.

    Predictors of mortality and limb loss in necrotizing soft tissue infections

    Arch Surg

    (2005)
  • S.K. Asfar et al.

    Necrotizing fasciitis

    Br J Surg

    (1991)
  • M. Bakleh et al.

    Correlation of histopathologic findings with clinical outcome in necrotizing fasciitis

    Clin Infect Dis

    (2005)
  • A. Barzilai et al.

    Necrotizing fasciitis: early awareness and principles of treatment

    Isr J Med Sci

    (1985)
  • B.D. Bilton et al.

    Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study

    Am Surg

    (1998)
  • M.M. Brandt et al.

    Necrotizing soft tissue infections: a surgical disease

    Am Surg

    (2000)

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