Necrotizing soft tissue infection: Difference between revisions
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+ | ==Background== |
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+ | ===Microbiology=== |
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+ | *See Classification, below |
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+ | *Most commonly caused by monomicrobial [[Streptococcus pyogenes]], [[Staphylococcus aureus]], [[Clostridium]], or [[Vibrio]], or polymicrobial infections that include Gram-positives, Gram-negatives, and anaerobes |
===Classification=== |
===Classification=== |
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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 monomicrobial) and Type 4 (fungal). |
| − | * |
+ | *'''Type 1:''' polymicrobial, including [[Staphylococcus aureus]], [[Gram-negative bacilli]], and [[anaerobes]] |
*'''Type 2:''' monomicrobial Gram-positive infections, primarily [[Streptococcus pyogenes]] (most common) but also [[Staphylococcus aureus]] or ''[[Clostridium]]'' (penetrating trauma, soil exposure) |
*'''Type 2:''' monomicrobial Gram-positive infections, primarily [[Streptococcus pyogenes]] (most common) but also [[Staphylococcus aureus]] or ''[[Clostridium]]'' (penetrating trauma, soil exposure) |
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*'''Type 3:''' monomicrobial Gram-negative infections, generally caused by water-associated ''[[Vibrio vulnificus]]'' or ''[[Aeromonas hydrophila]]'' |
*'''Type 3:''' monomicrobial Gram-negative infections, generally caused by water-associated ''[[Vibrio vulnificus]]'' or ''[[Aeromonas hydrophila]]'' |
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*Surgical debridement! |
*Surgical debridement! |
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*Empiric antibiotics |
*Empiric antibiotics |
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| − | **[[Piperacillin-tazobactam]] |
+ | **[[Piperacillin-tazobactam]] 4.5 g IV q8h (or, alternatively, [[meropenem]]) |
| − | **[[Clindamycin]], for synergy and the Eagle phenomenon and decreased toxin production |
+ | **[[Clindamycin]] 600 to 900 mg IV q8h, for synergy and the Eagle phenomenon and decreased toxin production |
| − | ** |
+ | **If risk for MRSA, add [[vancomycin]] 15-20 mg/kg IV q8-12h |
| + | **If water exposure, add two of: a [[Fluoroquinolones|fluoroquinolone]], a [[Carbapenems|carbapenem]], a third-generation [[Cephalosporins|cephalosporin]], and/or [[doxycycline]] (should have double-coverage pending susceptibilities) |
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| + | **Some recommend replacing [[clindamycin]] (and possibly [[vancomycin]]) with [[linezolid]]<ref>Nicolás Cortés-Penfield, Jonathan H Ryder, Should Linezolid Replace Clindamycin as the Adjunctive Antimicrobial of Choice in Group A Streptococcal Necrotizing Soft Tissue Infection and Toxic Shock Syndrome? A Focused Debate, ''Clinical Infectious Diseases'', 2022;, ciac720, https://doi.org/10.1093/cid/ciac720</ref> |
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*Then narrow based on the Gram stain an culture |
*Then narrow based on the Gram stain an culture |
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| − | *Can consider IVIg, rarely, in [[toxic shock syndrome]] |
+ | *Can consider IVIg, rarely, in [[streptococcal toxic shock syndrome|streptococcal]] or [[staphylococcal toxic shock syndrome]] |
===Eagle Effect=== |
===Eagle Effect=== |
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Latest revision as of 06:15, 4 September 2022
Background
Microbiology
- See Classification, below
- Most commonly caused by monomicrobial Streptococcus pyogenes, Staphylococcus aureus, Clostridium, or Vibrio, or polymicrobial infections that include Gram-positives, Gram-negatives, and anaerobes
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 monomicrobial) and Type 4 (fungal).
- Type 1: polymicrobial, including Staphylococcus aureus, Gram-negative bacilli, and anaerobes
- Type 2: monomicrobial Gram-positive infections, primarily Streptococcus pyogenes (most common) but also Staphylococcus aureus or Clostridium (penetrating trauma, soil exposure)
- Type 3: monomicrobial Gram-negative infections, generally caused by water-associated Vibrio vulnificus or Aeromonas hydrophila
- Type 4: fungal, caused by Candida species, and exceedingly rare
Management
- Surgical debridement!
- Empiric antibiotics
- Piperacillin-tazobactam 4.5 g IV q8h (or, alternatively, meropenem)
- Clindamycin 600 to 900 mg IV q8h, for synergy and the Eagle phenomenon and decreased toxin production
- If risk for MRSA, add vancomycin 15-20 mg/kg IV q8-12h
- If water exposure, add two of: a fluoroquinolone, a carbapenem, a third-generation cephalosporin, and/or doxycycline (should have double-coverage pending susceptibilities)
- Some recommend replacing clindamycin (and possibly vancomycin) with linezolid[1]
- Then narrow based on the Gram stain an culture
- Can consider IVIg, rarely, in streptococcal or staphylococcal 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.
- ↑ Nicolás Cortés-Penfield, Jonathan H Ryder, Should Linezolid Replace Clindamycin as the Adjunctive Antimicrobial of Choice in Group A Streptococcal Necrotizing Soft Tissue Infection and Toxic Shock Syndrome? A Focused Debate, Clinical Infectious Diseases, 2022;, ciac720, https://doi.org/10.1093/cid/ciac720
