Orthopaedic Knowledge Update®: Musculoskeletal Infection 2 Print + Ebook (AAOS - American Academy of Orthopaedic Surgeons)

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CHAPTER

Necrotizing Fasciitis and Other Complicated Skin and Soft-Tissue Infections

JOYA-RITA HINDY, MD • SARA F. HADDAD, MD LARRY M. BADDOUR, MD, FIDSA, FAHA

INTRODUCTION Microbial invasion of the skin and surrounding tissues leads to skin and soft-tissue infections (SSTIs). Surgery is often critical in the management of infectious syn dromes addressed in this chapter, and a consultation may be needed on an immediate or emergent basis to ultimately save the affected limb and the patient’s life. The limb perspective is of keen interest as most syn dromes discussed herein involve an extremity. Without emergent surgical intervention for securing source con trol, and despite appropriate antimicrobial administra tion, important outcomes including the need for critical care support, hospital length of stay, readmission rates, ability to ambulate, multiple surgeries, and short-term and long-term mortality, worsen by the hour. This chap ter focuses primarily on nonsurgical aspects of patient care, and reviews these complicated SSTIs: necrotizing soft-tissue infections (NSTIs) (such as cellulitis, fasci itis, myositis), animal bites in proximity to joints, and deep-seated abscesses (such as pyomyositis). The clinical variability and complexity of these complicated SSTIs, however, dictate that the diagnostic and management recommendations included herein be used to support and not supplant decisions regarding individual patient care. CLASSIFICATION OF SSTIS SSTIs are one of the most common types of infection encountered in an array of clinical settings. 1 These infec tions can involve any soft-tissue layer, including the epi dermis, dermis, subcutaneous tissue, fascia, and skeletal muscle. Complicated SSTIs are usually deep soft-tissue infections and encompass an array of conditions that may be classified as necrotizing or nonnecrotizing. A

ABSTRACT Complicated skin and soft-tissue infections (SSTIs) characterize the more extreme zone of the SSTI spec trum and may involve any or all of the soft-tissue lay ers, namely epidermis, dermis, subcutaneous tissue, fascia, and skeletal muscle. Several complicated SSTIs have been defined and include necrotizing soft-tissue infections (NSTIs), surgical site infections, animal bite infections, and deep abscesses (such as pyomyositis). NSTIs, which include necrotizing cellulitis, necrotiz ing fasciitis, and necrotizing myositis, deserve special attention because they are life-threatening infections presenting acutely (within hours) and may lead to limb loss and in-hospital mortality with delays in surgical intervention. Early recognition and aggres sive surgical débridement are fundamental in NSTIs management. In addition to antimicrobial therapy, complicated SSTIs usually require surgical manage ment (typically serial interventions) including incision and drainage and débridement. Often, surgeons are involved in the treatment of patients with NSTIs and other complicated infections.

Section 6: Bone, Joint, and Soft-Tissue Infections

Keywords: complicated skin and soft-tissue infections; necrotizing fasciitis; outcomes; pyomyositis; surgical management Dr. Baddour or an immediate family member has received royalties from UpToDate, Inc. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Hindy and Dr. Haddad. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

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Orthopaedic Knowledge Update ® : Musculoskeletal Infection 2