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Necrotizing Soft Tissue Infections and Other Soft Tissue Infections

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

An 18‐year‐old patient presents to the emergency room after being involved in a motor vehicle collision. He suffers a mild traumatic brain injury (TBI) and a 4% total body surface area (TBSA) abrasion of his right arm. The patient remains as an inpatient for 5 days for topical wound care and TBI evaluations. On the day of discharge, the patient reports worsening erythema at the proximal aspect of the right arm abrasion. The patient has approximately 4 cm of erythematous skin that has mild tenderness to palpation. The patient has normal vitals and normal labs. No bullae, fluctuance, or crepitus is present, and there is no pain‐out‐of‐proportion to exam. Some mild induration is appreciated around the wound bed, and a bedside ultrasound fails to reveal an organized fluid collection. What is the appropriate next step in management of this patient?
1. Discharge home with typical outpatient follow up in 2 weeks
2. Bedside incision and drainage
3. Cephalexin
4. Vancomycin IV, piperacillin/tazobactam IV, and clindamycin IV
5. Emergent surgical exploration and debridement
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.
A 20‐year‐old college athlete presents to the emergency room with a 1 cm abscess on his right medial thigh 10 cm inferior to the inguinal ligament. There is no associated cellulitis. The patient has normal vital signs, an unremarkable physical exam other than appropriate tenderness around the abscess, and unremarkable labs. He has a history of MRSA infections. What is the next step in management?
1. Incision and drainage
2. Incision and drainage with a course of oral cephalexin
3. Incision and drainage with a course of oral trimethoprim‐sulfamethoxazole (TMP‐SMX)
4. Computed tomography (CT) scan with IV contrast of the right lower extremity
5. Wide local excision and operative exploration
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.
A 38‐year‐old patient presents to the emergency room with a chief complaint of right arm pain. The patient reports that he is an IV drug abuser and uses dirty needles. The injection site has become more and more painful. There is significant erythema and induration along the majority of the right arm around the wound site for several centimeters circumferentially. The patient reports that these changes have happened rapidly over the previous 6 hours. The patient has pain‐out‐of‐proportion to exam with light touch eliciting a vigorous pain response. The patient does not have bullae or palpable crepitus on exam. The patient is febrile, tachycardic, and normotensive. What is the next best step in management?
1. Bedside incision and drainage
2. Perform a laboratory assessment and a CT scan with IV contrast of the right arm
3. Admit the patient to the floor and start cefazolin IV
4. Admit the patient to the ICU and start vancomycin, clindamycin, and piperacillin/tazobactam IV
5. Emergency incision, drainage, and wide local excision of all devitalized tissues
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.
A 64‐year‐old patient presents to the emergency department with increasing pain at a left leg venous stasis ulcer site. The patient has dealt with venous stasis disease for years and has developed a venous stasis ulcer on the medial aspect of his medial malleolus. This wound has been present for weeks. Three days ago the patient reported onset of pain, redness, and induration at the site, and over the last 12 hours, the pain is worsening and the redness has progressed. The patient has pain with passive flexion/extension of the ankle. Laboratory testing is performed in the emergency department and reveals the following data:
- White blood cell count (WBC): 23.8 cell/mm³
- Hemoglobin: 10.6 g/dL
- Hematocrit: 29.4 g/dL
- Platelets: 445
- Sodium: 132 mmol/L
- Potassium: 4.2
- Chloride: 102
- Bicarbonate: 20
- Blood urea nitrogen (BUN): 58
- Creatinine: 2.3 mg/dL
- Glucose: 224 mg/dL
- C‐reactive protein (CRP): 228 mg/L
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