MAJ Jacob Swann, MD1 and Joseph DuBose, MD2 1 Regions Hospital, Saint Paul, MN, USA 2 Department of Surgery, Dell School of Medicine, University of Texas Austin, Austin, TX, USA This patient is presenting with uncomplicated cellulitis. The patient has an open wound that became subsequently infected likely secondary to skin flora. This patient warrants a course of antibiotics to treat the cellulitis. First‐line therapy for cellulitis is an assessment to ensure no evidence of a drainable fluid collection is present. Once significant occult pathology is ruled out, initiation of antibiotics is appropriate. If there are no systemic signs of inflammation (i.e. fever, tachycardia, or leukocytosis), a 5‐day course of oral antibiotics is recommended by the Infectious Disease Society of America (IDSA); appropriate therapy includes cephalexin, or clindamycin if the patient has a severe penicillin allergy. This course can be extended based on the patient’s response to therapy. If the patient has a history of methicillin‐resistant Staphylococcus aureus (MRSA) positivity or is high risk for MRSA infection (i.e. positive screening nasal swab, prior MRSA wound cultures, or a personal history of IV drug abuse), then using a medication with MRSA coverage is first‐line therapy. In this scenario, with no fluctuance on exam and an ultrasound showing no fluid collection, there is no need for an incision and debridement at the site. Similarly, the patient does not appear to have a necrotizing soft tissue infection (no bullae, crepitus, or pain out of proportion to exam); as such, emergent exploration, debridement, or broad‐spectrum antibiotics are not indicated. Discharge home without intervention is inappropriate as the patient has active cellulitis. Thus, the correct answer is to start cephalexin. Answer: C Stevens, DL, Bisno AL, Chambers HF, et al. “Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 updated by the infectious diseases society of America.” Clinical Infectious Diseases. 2014; 59 (2): e10–e52. This patient has a simple abscess without evidence of systemic inflammation. Traditional teaching would recommend incision and drainage alone is likely adequate therapy for this patient with no evidence of systemic inflammation or superimposed cellulitis. However, emerging literature supports a short course of therapy with oral TMP‐SMX or clindamycin for simple abscesses. Several recent studies have shown a decreased rate of treatment failure (i.e. recurrent abscess) or recurrence. However, with the use of antibiotics, there is an increased risk of side effects, namely, an increase in GI symptoms and diarrhea. In these studies, cephalosporins did not reduce treatment failure risk. While the IDSA has not published new guidelines on this subject, it appears likely that a recommendation will change in the coming guidelines for skin/soft tissue infections. Referencing the latest IDSA guidelines, collecting abscess fluid cultures are ideal for any drainable fluid collection, however the IDSA does not support culturing wounds in the setting of simple abscesses as it will not guide antibiotic therapy. In this question stem, further imaging for a simple abscess is not indicated given the well‐circumscribed nature of the abscess. There is no role for wide local excision of a simple abscess as this is not an NSTI. Cephalexin is suboptimal when compared to TMP‐SMX or clindamycin. Simple incision and drainage is associated with a higher treatment failure rate. Answer: C Duam, RS, Miller LG, Immergluck L, et al. “A placebo‐controlled trial of antibiotics for smaller skin abscesses.” The New England Journal of Medicine. 2017; 376 (26): 2545–2555. Vermandere, M., Aertgeerts B, Agoritsas T, et al. “Antibiotics after incision and drainage for uncomplicated skin abscesses: a clinical practice guideline.” The British Medical Journal. 2018; 360: k243. Wang, W., Chen W., Liu Y., et al. “Antibiotics for uncomplicated skin abscesses: systemic review and network meta‐analysis.” BMJ Open. 2018; 8: e020991. The patient is presenting with many signs and symptoms concerning for a necrotizing soft tissue infection (NSTI). The patient has signs of systemic inflammation as evidenced by the vital sign abnormalities. On exam, the patient has pain‐out‐of‐proportion to exam with a rapidly spreading cellulitis. The patient also has a high‐risk exposure history with use of dirty needles for his IV drug abuse. With this constellation of symptoms, the patient has a presumptive diagnosis of an NSTI and needs to proceed to the operating room emergently for exploration and wide debridement. Early debridement and sufficient debridement are the two best predictors of survival in this disease process. Bedside incision and drainage of the wound site is unlikely to obtain adequate source control of the rapidly spreading bacterial infection. Insufficient debridement is associated with a higher mortality. Further workup with laboratory and imaging workups will not add any additional data that would make the patient a nonoperative candidate. This would only delay his time to the operating room (OR). Initiation of appropriate antibiotics (vancomycin, clindamycin, and piperacillin/tazobactam) is important for this patient; however, doing so should not delay going to the operating room. Moreover, admitting the patient to the ICU or a lower level of care in lieu of the operating room will add mortality to this patient as the patient needs to be emergently operated on to obtain surgical source control. Answer: E Nawijn F, Smeeing DPJ, Houwert RM, et al. “Time is of the essence when treating necrotizing soft tissue infections: a systemic review and meta‐analysis.” World Journal of Emergency Surgery. 2020; 15: 4.
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Necrotizing Soft Tissue Infections and Other Soft Tissue Infections
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