Necrotizing soft tissue infection: Difference between revisions
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Although it is classically divided into Type 1 (polymicrobial) and Type 2 (monomicrobial), others have proposed an extension to include Type 3 (water-associated) and Type 4 (fungal). |
Although it is classically divided into Type 1 (polymicrobial) and Type 2 (monomicrobial), others have proposed an extension to include Type 3 (water-associated) and Type 4 (fungal). |
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| − | * '''Type 1:''' polymicrobial, including '' |
+ | * '''Type 1:''' polymicrobial, including ''[[Staph. aureus]]'', [[Gram-negatives bacilli]], and [[anaerobes]] |
| − | * '''Type 2:''' monomicrobial Group A Streptococcus (''Strep. pyogenes'') |
+ | * '''Type 2:''' monomicrobial [[Group A Streptococcus]] (''Strep. pyogenes'') |
| − | ** May include '' |
+ | ** May include ''[[Staph. aureus]]'', ''[[Clostridium]]'' (penetrating trauma, soil exposure), ''[[Vibrio]]'' (water), ''[[Aeromonas]]'' (water) |
| − | * '''Type 3:''' monomicrobial Gram-negative infections, generally caused by water-associated ''Vibrio vulnificans'' or ''Aeromonas hydrophila'' |
+ | * '''Type 3:''' monomicrobial Gram-negative infections, generally caused by water-associated ''[[Vibrio vulnificans]]'' or ''[[Aeromonas hydrophila]]'' |
| − | * '''Type 4:''' fungal, caused by ''Candida'' species, and exceedingly rare |
+ | * '''Type 4:''' fungal, caused by ''[[Candida]]'' species, and exceedingly rare |
== Management == |
== Management == |
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Revision as of 07:55, 16 August 2019
Classification
Although it is classically divided into Type 1 (polymicrobial) and Type 2 (monomicrobial), others have proposed an extension to include Type 3 (water-associated) and Type 4 (fungal).
- Type 1: polymicrobial, including Staph. aureus, Gram-negatives bacilli, and anaerobes
- Type 2: monomicrobial Group A Streptococcus (Strep. pyogenes)
- May include Staph. aureus, Clostridium (penetrating trauma, soil exposure), Vibrio (water), Aeromonas (water)
- Type 3: monomicrobial Gram-negative infections, generally caused by water-associated Vibrio vulnificans or Aeromonas hydrophila
- Type 4: fungal, caused by Candida species, and exceedingly rare
Management
- Surgical debridement!
- Empiric antibiotics
- Piperacillin-tazobactam
- Clindamycin, for synergy and the Eagle phenomenon and decreased toxin production
- +/- vancomycin
- Then narrow based on the Gram stain an culture
- Can consider IVIg, rarely, in toxic shock syndrome
Eagle Effect
- Originally, referred to decreased effectiveness of penicillins at high concentrations
- Now, refers to decreased effectiveness of penicillins at high bacterial burden (when in stationary phase)
- Clindamycin kills enough of the bacteria that are in stationary phase that the bacteria return to logarithmic growth phase, where penicillins are more effective
Further Reading
- RCT of IVIG: Madsen MB et al. Immunoglobulin G for patients with necrotising soft tissue infection (INSTINCT): a randomised, blinded, placebo-controlled trial. Intensive Care Med. 2017;43:1585-93.
