IN THE NAME OF THE MOST HIGH. SKIN AND SOFT TISSUE INFECTIONS.
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Transcript of IN THE NAME OF THE MOST HIGH. SKIN AND SOFT TISSUE INFECTIONS.
IN THE NAME IN THE NAME OF THE OF THE
MOST HIGHMOST HIGH
SKIN AND SKIN AND SOFT SOFT
TISSUE TISSUE INFECTIONSINFECTIONS
PHYSICAL CHARACTERISTICS PHYSICAL CHARACTERISTICS OF THE SKINOF THE SKIN
Mechanical barrier of stratum corneumMechanical barrier of stratum corneum
Relatively low PH(~5.5)Relatively low PH(~5.5)
Natural antibacterial substances in the Natural antibacterial substances in the secretions of sebaceous glandssecretions of sebaceous glands
Relative dryness of normal skinRelative dryness of normal skin
Bacterial interferenceBacterial interference
PREDISPOSING FACTORSPREDISPOSING FACTORSDisruption of stratum corneumDisruption of stratum corneum
Burn and bites Burn and bites
abrasion abrasion
Surgery Surgery
Vascular/pressure ulcerVascular/pressure ulcer
Underlying condition (dermatitis ,HSV, varicella)Underlying condition (dermatitis ,HSV, varicella)
injectionsinjections
Foreign body ( IV cath. Suture )Foreign body ( IV cath. Suture )
Hair follicle : normal floraHair follicle : normal flora
extrinsic bacteriaextrinsic bacteria
PREDISPOSING FACTORSPREDISPOSING FACTORS
Reduced vascular supplyReduced vascular supplyDisruption of lymphatic or venous Disruption of lymphatic or venous
drainagedrainageCompromised immune systemCompromised immune system
IMPETIGOIMPETIGO
EtiologyEtiology
gASgAS
Staphylococcus aureus Staphylococcus aureus (MRSA has (MRSA has been reported)been reported)
gCS gCS rarelyrarely
gGSgGS
Gbs Gbs (in newborn)(in newborn)
EpidemiologyEpidemiologygAS: -hot,humid,summer weather gAS: -hot,humid,summer weather (tropical, semitropical)(tropical, semitropical)
-young children (2 – 5 y)-young children (2 – 5 y) -follows -follows skin colonizationskin colonization by 10d by 10d --sporadicsporadic cases in cooler climates may cases in cooler climates may
be due to contagious spread from be due to contagious spread from nasopharynxnasopharynx Highly communicableHighly communicable Related to PSGN but not ARF Related to PSGN but not ARF
S.aereus: -follow nasal colonization S.aereus: -follow nasal colonization
Predisposing factorPredisposing factor
Poor hygienePoor hygieneCrowdingCrowding
Minor trauma (scratch)Minor trauma (scratch)
Insect biteInsect bite
Preexisting skin disease(dermatitis)Preexisting skin disease(dermatitis)
Clinical manifestationClinical manifestation
Red papule Red papule Small vesicle Small vesicle pustulate pustulate rupture rupture
Thick yellow stuck-on crustsThick yellow stuck-on crustsUsual siteUsual site: face(around the nose and mouth): face(around the nose and mouth)
legslegsPainlessPainlessPruriticPruriticMild regional adenopathyMild regional adenopathyMinimal constitutional symptomsMinimal constitutional symptomsRecovery without scarRecovery without scar
Bullous impetigoBullous impetigo
S.aureusS.aureus
Newborn and younger childrenNewborn and younger children
10% of all cases of impetigo10% of all cases of impetigo
Epidermal split caused by Epidermal split caused by exfoliative toxinexfoliative toxin
More extensive lesions More extensive lesions
1-2 cm bullae containing neutrophils and 1-2 cm bullae containing neutrophils and organismorganism
thin paper-like cruststhin paper-like crusts
TREATMENTTREATMENT
Topical mupirocinTopical mupirocin
PRP cloxacillin 250mg qidPRP cloxacillin 250mg qid
11stst g. ceph. cephalexin 250mg qid g. ceph. cephalexin 250mg qid
In the past penicillins (benzathin,oral P.V,In the past penicillins (benzathin,oral P.V,
amoxicillin)amoxicillin) in case of allergy: erythromycinin case of allergy: erythromycin duration : 10dduration : 10d
FOLLICULITISFOLLICULITIS
General considerationsGeneral considerations
Etiology:Etiology: Staphylococcus.aureus Staphylococcus.aureusSuperficial infection within Superficial infection within hair follicleshair follicles & & apocrine regionapocrine regionpapulepapulesmall(2-5mm)small(2-5mm)erythematouserythematousOccasionally pruriticOccasionally pruriticTopped by a central pustuleTopped by a central pustule
TreatmentTreatment
Local measuresLocal measures
saline compresssaline compress
topical antibacterialstopical antibacterials
Duration :until resolution of infection Duration :until resolution of infection
(5-7 d)(5-7 d)
Chronic folliculitis: Chronic folliculitis: Uncommon except in acne vulgaris,Uncommon except in acne vulgaris, Constituents of the normal flora Constituents of the normal flora ((ee..gg.., ,
Propionibacterium acnesPropionibacterium acnes)) may play a may play a rolerole
Diffuse folliculitis:Diffuse folliculitis:Hot-tub folliculitisSwimmer’s itch
Hot-tub folliculitisHot-tub folliculitisPseudomona.aeruginosa:Pseudomona.aeruginosa:
-contaminated swimming pools-contaminated swimming pools insufficiently chlorinatedinsufficiently chlorinated , , 37-40°c 37-40°c --IP:IP:48h48h -papulourticarial-papulourticarialpustulepustule -healing within -healing within 55 days days --bacteremiabacteremia has been reported has been reported
swimmer’s itchswimmer’s itch
Exposure of skin to freshwater infested Exposure of skin to freshwater infested with with avian schistosomesavian schistosomesWarmWarm water and water and alkalinealkaline PH: PH:
suitable for molluskssuitable for mollusks(intermediate host)(intermediate host)
Schistosomal cercariae penetrate hair Schistosomal cercariae penetrate hair follicles but quickly diesfollicles but quickly diesAllergic reactionAllergic reaction : intense itching and : intense itching and erythemaerythema
Other less common formsOther less common forms
EnterbacteriaceaeEnterbacteriaceae
-complicate acne-complicate acne
-during prolonged AB therapy-during prolonged AB therapy
CandidaCandida
-surrounding areas of intertriginous-surrounding areas of intertriginous
-pruritic satellite lesion-pruritic satellite lesion
-prolonged AB or C.S -prolonged AB or C.S
FURUNCLE&CARBUNCLEFURUNCLE&CARBUNCLE
FuruncleFuruncle
Deep seated Deep seated (subcut.)(subcut.) necrotic infection necrotic infection
Extend from a hair follicle to a true abscessExtend from a hair follicle to a true abscess
Site:areas that are subject to areas that are subject to frictionfriction and and perspiration perspiration and contain and contain hair follicleshair follicles (buttock,face,neck)(buttock,face,neck)
Painful , firm, red nodulePainful , firm, red nodule
Fever and constitutional symptoms Fever and constitutional symptoms
Subside after spontaneous drainageSubside after spontaneous drainage
CarbuncleCarbuncleDeep infectionDeep infection of a group of contiguous of a group of contiguous folliclesfollicles
Site: back of the neck,shoulders,hip,thigh: back of the neck,shoulders,hip,thigh
More severe,necrotic and painfulMore severe,necrotic and painful
External drainage along hair folliculesExternal drainage along hair follicules
Intense inflammation of surrounding and Intense inflammation of surrounding and underlying connective tissueunderlying connective tissue
Fever ,malaise and leukocytosisFever ,malaise and leukocytosis
Predisposing factorsPredisposing factors
Diabetes mellitusDiabetes mellitus
ObesityObesity
Blood dyscrasiaBlood dyscrasia
Corticosteroid therapyCorticosteroid therapy
Defect in neutrophil functionDefect in neutrophil function
ComplicationComplication
Blood stream invasionBlood stream invasion
Infective endocarditisInfective endocarditis
Metastatic fociMetastatic foci
OsteomyelitisOsteomyelitis
Upper lip,noseUpper lip,nose: : spread to cavernous spread to cavernous sinussinus
TreatmentTreatmentSystemic antibiotics esp. if cellulitisSystemic antibiotics esp. if cellulitis
feverfever midfacemidface
SevereSevere infection: nafcillin/cloxacillin infection: nafcillin/cloxacillin 1-2g iv q4h1-2g iv q4h cefazolin 1g iv q8hcefazolin 1g iv q8h
MildMild infection: cloxacillin/cephalexin infection: cloxacillin/cephalexin 250-500mg po qid250-500mg po qid
Duration :Duration : 7-10d 7-10dSurgerySurgery: large and fluctuent: large and fluctuent
FuruncleFuruncle
FuruncleFuruncle
CarbuncleCarbuncle
ERYSIPELASERYSIPELAS
EtiologyEtiology
gAStrepgAStrep
Uncommonly gC & gGStrepUncommonly gC & gGStrep
In newborns gBStrepIn newborns gBStrep
Clinical manifestationClinical manifestationSiteSite: : formerlyformerly face was most common face was most common
nownow distribution has changed: distribution has changed:
70-80% lower extremity70-80% lower extremity
5-20% face5-20% face
Infants and elderly adults most affectedInfants and elderly adults most affected
Clinical manifestationClinical manifestation
Abrupt onsetAbrupt onset
Rapid progressionRapid progression Translocation of strep. laterally via lymphaticsTranslocation of strep. laterally via lymphatics
Flaccid edema of the epidermisFlaccid edema of the epidermis Engorgement or obstruction of lymphaticsEngorgement or obstruction of lymphatics
Clinical manifestationClinical manifestationBright,redBright,red swelling swellingWarm , intense painWarm , intense painRaised,indurated,sharply demarcated Raised,indurated,sharply demarcated marginmarginPeau d ‘ orangePeau d ‘ orange texture texture
involvement of superficial lymphaticinvolvement of superficial lymphaticFlaccid bullae during Flaccid bullae during 22ndnd or 3 or 3rdrd day dayDesquamationDesquamation 5-10 days5-10 days in to the illness in to the illnessFever , leukocytosis is a feature Fever , leukocytosis is a feature Extension to deeper soft tissue is rare Extension to deeper soft tissue is rare
TreatmentTreatmentMild,early: -procaine penicillin 1.2mu bid IMMild,early: -procaine penicillin 1.2mu bid IM
-penicillin.V oral-penicillin.V oral -erythromycin in case of allergy -erythromycin in case of allergy
Severe : -penicillin.G 1-2mu q4h IVSevere : -penicillin.G 1-2mu q4h IV
If cellulitis is a D.Dx: -PRP(nafcillin,oxacillin)If cellulitis is a D.Dx: -PRP(nafcillin,oxacillin) -1-1stst g. ceph. g. ceph.
TreatmentTreatmentSwelling may progress despite appropriate Swelling may progress despite appropriate treatmenttreatment
FeverFever
Pain diminishPain diminish
Intense red colorIntense red color
CELLULITISCELLULITIS
EtiologyEtiology
S.aereus:S.aereus:MRSA is rapidly replacing MSSAMRSA is rapidly replacing MSSA
gA strep.gA strep.gC strep sometimes gC strep sometimes gG strep sometimesgG strep sometimes
Wide variety of exogenous bacteriaWide variety of exogenous bacteria
Predisposing factorPredisposing factorS.aureusS.aureus : : central localized infectioncentral localized infection (e.g. abscess , folliculitis , infected foreign (e.g. abscess , folliculitis , infected foreign body , surgical or traumatic wounds)body , surgical or traumatic wounds)
Strep.Strep. : : minor or inapparent breaks minor or inapparent breaks
disrupted lymphatic drainagedisrupted lymphatic drainage
surgical wound infectionsurgical wound infection (1(1stst 24 h ) 24 h )
Clinical manifestationClinical manifestationPain and local tendernessPain and local tenderness
Hot Hot
swollen swollen
ErythemaErythema
Strep Strep : more rapidly spreading: more rapidly spreading
frequently associated with fever frequently associated with fever
and lymphangitisand lymphangitis
Clinical manifestationClinical manifestation
Diffuse spreading infectionDiffuse spreading infection
Involves skin and subcutaneous tissueInvolves skin and subcutaneous tissue
(deeper than erysipelas)(deeper than erysipelas)
Systemic signs (fever,malaise,chills)Systemic signs (fever,malaise,chills)
Regional lymphadenopathyRegional lymphadenopathy
Border Border notnot elevated , elevated ,notnot demarcated demarcated
Diagnosis Diagnosis
IfIf : drainage : drainage
an open wound gram stain an open wound gram stain
an obvious port of entry culturean obvious port of entry culture
In the absence of these findings definite In the absence of these findings definite diagnosis of etiology is difficultdiagnosis of etiology is difficult
Culture of needle aspiration and punch Culture of needle aspiration and punch biopsy biopsy 20%20%
Blood culture Blood culture <5%<5%
Differential diagnosisDifferential diagnosis
Necrotizing fasciitisNecrotizing fasciitis
Insect biteInsect bite
Fixed drug eruptionFixed drug eruption
DVT DVT
FMFFMF
Pyoderma gangrenosaPyoderma gangrenosa
Sweet’s syndromeSweet’s syndrome
TreatmentTreatment
Indications for admission:Indications for admission:
- - rapid progressionrapid progression
- systemic reaction (chills and fever) - systemic reaction (chills and fever)
- underlying condition- underlying condition (immunedefficiency, asplenia, previous (immunedefficiency, asplenia, previous edema, cirrhosis, renal failure, heart edema, cirrhosis, renal failure, heart failure) failure)
Treatment Treatment Hospitalized patients:Hospitalized patients:
-Nafcillin or oxacillin 2g iv q4-6h-Nafcillin or oxacillin 2g iv q4-6h
-Cefazolin 1-2g iv q8h-Cefazolin 1-2g iv q8h
Mild infectionMild infection
-Cloxacillin 500mg po q6h-Cloxacillin 500mg po q6h
-Cephalexin 500mg po q6h-Cephalexin 500mg po q6h
Other agentsOther agents: vancomycin, clindamycin, : vancomycin, clindamycin, erythromycin, TMP/SMX, quinolones erythromycin, TMP/SMX, quinolones (CAMRSA)(CAMRSA)
TreatmentTreatment
Duration :Duration : 10-1410-14 days days
Shift from Shift from IVIV to to POPO after systemic symptoms after systemic symptoms and erythema resolvedand erythema resolved
Recurrent formsRecurrent forms
Saphenous venectomy for CABGSaphenous venectomy for CABG
Edema,erythema,tendernessEdema,erythema,tenderness
Chills,high fever,toxicityChills,high fever,toxicity
Associated lymphangitisAssociated lymphangitis
Spread along the course of venectomySpread along the course of venectomy
Etiology:gA & non gAßHS (gC,gG)Etiology:gA & non gAßHS (gC,gG)
Port of entry:associated area of tinea pedisPort of entry:associated area of tinea pedis
Recurrent formsRecurrent forms
Chronic lower extremity lymphedemaChronic lower extremity lymphedema
Radiation therapyRadiation therapy
Neoplastic involvement of pelvic lymph Neoplastic involvement of pelvic lymph nodenode
Lymph node dissectionLymph node dissection
Chronic venous stasis (prior DVT)Chronic venous stasis (prior DVT)
Recurrent formsRecurrent formsStapylococcus :Stapylococcus :
Job ‘s syndrome Job ‘s syndrome (eosinophilia and, IgE)(eosinophilia and, IgE) Nasal carriers of staph Nasal carriers of staph
Other microorganismsOther microorganismsS.agalactiae(gBS)S.agalactiae(gBS)
Elderly, diabetes, neurologic impairment, Elderly, diabetes, neurologic impairment, Peripheral vascular disease, HIV Peripheral vascular disease, HIV
Haemophilus.influenzaHaemophilus.influenzaChildrenChildrenViolaceous, facial cellulitis(periorbital,cheek)Violaceous, facial cellulitis(periorbital,cheek) In association with sinusitis,otitis,epiglotitisIn association with sinusitis,otitis,epiglotitis
Other microorganismsOther microorganisms
P.aeruginosaP.aeruginosa 3 types3 types of soft tissue infections: of soft tissue infections: Ecthyma gangrenosumEcthyma gangrenosum in neutropenic patients in neutropenic patients Hot tub folliculitisHot tub folliculitis Cellulitis :Cellulitis : penetrating injuries (step on a nail) penetrating injuries (step on a nail)
hospitalized immunocompromised hosthospitalized immunocompromised host
Treatment :surgical drainage and inspectionTreatment :surgical drainage and inspection
+ antimicrobial (+ antimicrobial (AG , 3AG , 3rdrd generation ceph. generation ceph.
, semisynthetic penicillin , quinolone), semisynthetic penicillin , quinolone)
Other microorganismsOther microorganismsPasteurella multocidaPasteurella multocida, Staphylococcus , Staphylococcus intermedius and Capnocytophaga intermedius and Capnocytophaga canimorsuscanimorsus
cat or dog bitecat or dog bite
Eikenella corrodensEikenella corrodens human bitehuman bite
AmoxicillinAmoxicillin//clavulanateclavulanate, , ampicillinampicillin//sulbactamsulbactam, , and and cefoxitincefoxitin are good choices for the treatment are good choices for the treatment of of animal animal or or humanhuman bite infections bite infections
Other microorganismsOther microorganismsErysipelothrix.rhusiopathiae Erysipelothrix.rhusiopathiae
Fish and domestic swine: butcher, fisherman, veterinarianFish and domestic swine: butcher, fisherman, veterinarian
Aeromonas hydrophiliaAeromonas hydrophilia Fresh water (lakes,rivers,streams)Fresh water (lakes,rivers,streams)
Vibrio vulnificus Vibrio vulnificus Seawater or seafoodsSeawater or seafoods
M. marinumM. marinum water in aquariums or swimming pools water in aquariums or swimming pools
NECROTIZING SOFT NECROTIZING SOFT TISSUE TISSUE
INFECTIONSINFECTIONS
Necrotizing fasciitisNecrotizing fasciitis
Destruction of Destruction of subcutaneous tissuesubcutaneous tissue and and fasciafascia
Physical findings ,Physical findings ,particularly earlyparticularly early in in the illness, may the illness, may notnot be striking when be striking when pain or unexplained feverpain or unexplained fever is the only is the only manifestation with no or minimal manifestation with no or minimal erythemaerythema
Infectious disease emergencyInfectious disease emergency
In In the initial phase distinguishing between the initial phase distinguishing between cellulitiscellulitis and and fasciitisfasciitis is difficultis difficult
Necrotizing fasciitisNecrotizing fasciitis Involvement of deeper tissue is suggested:Involvement of deeper tissue is suggested: Failure to respond to therapyFailure to respond to therapy Hard , wooden feel of subcutaneous tissueHard , wooden feel of subcutaneous tissue Systemic toxicitySystemic toxicity Bullous lesionBullous lesion Skin necrosis and ecchymosisSkin necrosis and ecchymosis Rapid spreadRapid spread Gas in soft tissueGas in soft tissue Edema that extends beyond the margin of erythemaEdema that extends beyond the margin of erythema Skin anesthesiaSkin anesthesia
Necrotizing fasciitisNecrotizing fasciitis
Clinical manifestationClinical manifestation : : severe local painsevere local painanesthesiaanesthesia cellulitis with progressive edema,erythemacellulitis with progressive edema,erythema dark red induration of epidermisdark red induration of epidermis bullae filled with blue or purple fluidbullae filled with blue or purple fluid friable skin with bluish ,maroon or black colorfriable skin with bluish ,maroon or black color thrombose of blood vessels in dermal papilla thrombose of blood vessels in dermal papilla crepitationcrepitation fever , systemic toxicity fever , systemic toxicity shock and multiorgan shock and multiorgan failure failure
Necrotizing fasciitisNecrotizing fasciitis
TYPE 1TYPE 1 :polymicrobial (anaerobe,g+ ,g- ):polymicrobial (anaerobe,g+ ,g- )
PredisposingPredisposing :- a breach in the integrity of mucous :- a breach in the integrity of mucous membrane (GI or GU) : malignancy , diverticulum …, urethral membrane (GI or GU) : malignancy , diverticulum …, urethral teartear
- surgery- surgery
- diabetes- diabetes
- peripheral vascular disease- peripheral vascular disease
- injection drug use- injection drug use
Necrotizing fasciitisNecrotizing fasciitisTYPE 2TYPE 2 : :gAstrep (streptococcal gangrene)gAstrep (streptococcal gangrene)
Predisposing Predisposing ::
- non penetrating minor trauma(a bruise, muscle - non penetrating minor trauma(a bruise, muscle strain) via transient bactremiastrain) via transient bactremia
- cutaneous infection , penetrating trauma- cutaneous infection , penetrating trauma
Toxicity is severeToxicity is severe
20-40% myositis occur concomitantly20-40% myositis occur concomitantly
Markedly elevated CPKMarkedly elevated CPK
Gas is not usually presentGas is not usually present
Fournier’s gangreneFournier’s gangrene
A type of necrotizing fasciitisA type of necrotizing fasciitis
Leakage to the Leakage to the perinealperineal area area
Mixed aerobe-anaerobe infectionMixed aerobe-anaerobe infection
Massive swelling of scrotum and penisMassive swelling of scrotum and penis
Extension to the Extension to the prineumprineum , , abdominal wallabdominal wall andand legs legs
Necrotizing fasciitisNecrotizing fasciitis Diagnosis :Diagnosis :
Vigilant and serial clinical examinationVigilant and serial clinical examination
Soft tissue radiographs and CTscans:Soft tissue radiographs and CTscans:
Local abscess or gasLocal abscess or gas
only soft tissue swelling in some casesonly soft tissue swelling in some cases
Aspiration of the leading edge or punch biopsy:Aspiration of the leading edge or punch biopsy:
false negative in nearly 80%false negative in nearly 80%
Open surgical inspection with debridementOpen surgical inspection with debridement
Necrotizing fasciitisNecrotizing fasciitis
RxRx : : surgical drainage and debridement:surgical drainage and debridement:
1) visualize the deep structure1) visualize the deep structure
2)remove necrotic tissue2)remove necrotic tissue
3)reduce compartment pressure3)reduce compartment pressure
4)obtain material for smear & culture4)obtain material for smear & culture
Hyperbaric oxygenHyperbaric oxygen
Necrotizing fasciitisNecrotizing fasciitisRx : Rx : type 1type 1 Ampicillin or ampicillin/sulbactam+ Ampicillin or ampicillin/sulbactam+
Gentamicin+Gentamicin+ metronidazole/clindamycinmetronidazole/clindamycin
ampicillin +ampicillin + ciprofluxacin+ciprofluxacin+ metronidazole/clindamycinmetronidazole/clindamycin
type 2type 2 penicillin G + penicillin G + clindamycinclindamycin
Clostridial gas gangreneClostridial gas gangrene(clostridial myonecrosis)(clostridial myonecrosis)
EtiologyEtiology
Clostridial spp.Clostridial spp.C.perfringesC.perfringes 80 % of cases 80 % of cases
-trauma -trauma
need not to be severeneed not to be severe
but must be deep&necroticbut must be deep&necrotic
-surgery-surgery
-intramuscular injection-intramuscular injection
EtiologyEtiology
C.septicumC.septicumspontanous,nontraumaticspontanous,nontraumatic
GI abn (GI abn (cancercancer,surgery,diverticulitis),surgery,diverticulitis)
leukemia,lymphomaleukemia,lymphoma
neutropenianeutropenia
HIV infectionHIV infection
Clinical manifestationClinical manifestation
Short IP almost always<3d frequently<24hShort IP almost always<3d frequently<24hSudden onset of exquisite increasing painSudden onset of exquisite increasing painLocal swelling and edemaLocal swelling and edemaThin hemorrhagic exudateThin hemorrhagic exudateFrothiness of wound exudateFrothiness of wound exudateTachycardia ,minor elevation in temperatureTachycardia ,minor elevation in temperatureGas may be Gas may be absentabsent at early stages at early stages
Clinical manifestationClinical manifestationSkin is tense , white marbled with blue and Skin is tense , white marbled with blue and cooler than normalcooler than normal
Rapid progression of edema & toxemiaRapid progression of edema & toxemia
Profuse serosanginous discharge with Profuse serosanginous discharge with sweetishsweetish smell smell
Bullae ,patches of cutaneous gangrene, Bullae ,patches of cutaneous gangrene, bronze discolorationbronze discoloration
Gas in affected tissueGas in affected tissue
Clinical manifestationClinical manifestation
High LOC until just before deathHigh LOC until just before death
Hypotension ,renal failureHypotension ,renal failure
At surgery -muscle may appear paleAt surgery -muscle may appear pale
-does not contract-does not contract
-beefy red and nonviable when-beefy red and nonviable when
dissecteddissected
Diagnosis & TreatmentDiagnosis & Treatment
Gram stainGram stain :gram positive bacilli (box car) :gram positive bacilli (box car)
paucity of PMNpaucity of PMN
Surgery: Surgery: muscles are pale ,nonviablemuscles are pale ,nonviable
frozen sectionfrozen section
RxRx:: surgicalsurgical removal of devitalized tissue removal of devitalized tissue
antibiotic antibiotic : clindamycin + penicillin: clindamycin + penicillin
metronidazolemetronidazole
chloramphenicolchloramphenicol
hyperbaric oxygenhyperbaric oxygen
DIABETIC FOOT ULCERSDIABETIC FOOT ULCERS
Chronic foot infections in patients with D.M Chronic foot infections in patients with D.M are common and difficult problemsare common and difficult problems
Minor trauma in presence of Minor trauma in presence of peripheral neuropathy , neuropathic peripheral neuropathy , neuropathic ulcers , vascular insufficiencyulcers , vascular insufficiency
Different forms : cellulitis , tissue Different forms : cellulitis , tissue necrosis , osteomyelitisnecrosis , osteomyelitis
Clinical manifestationClinical manifestationNon limb threateningNon limb threatening
SuperficialSuperficial
Lack of systemic toxicityLack of systemic toxicity
Minimal cellulitis < 2 cm from port of Minimal cellulitis < 2 cm from port of entryentry
Ulceration (if present) not fully extending Ulceration (if present) not fully extending through the skinthrough the skin
Lack of significant ischemiaLack of significant ischemia
Clinical manifestationClinical manifestation
Limb threatening :Limb threatening :
More extensive cellulitisMore extensive cellulitis
LymphangitisLymphangitis
Ulcer penetrating through skin in to Ulcer penetrating through skin in to subcutaneous tissuesubcutaneous tissue
Prominent ischemiaProminent ischemia
Etiology Etiology
Non limb threatening :Non limb threatening :
S.aureus is major pathogenS.aureus is major pathogen
Facultative streptococci in one thirdFacultative streptococci in one third
Facultative gram negative and anaerobe Facultative gram negative and anaerobe are uncommonare uncommon
Limb threatening :Limb threatening :
Polymicrobial Polymicrobial (S.aureus ,Gbstrep. ,facultative gram (S.aureus ,Gbstrep. ,facultative gram negative ,anaerobe)negative ,anaerobe)
Medical TreatmentMedical Treatment
Non limb threatening :Non limb threatening :
Mild : oral cephalexin , cloxacillin , Mild : oral cephalexin , cloxacillin ,
clindamycinclindamycin
Complicated by cellulitis :parentral cephazolinComplicated by cellulitis :parentral cephazolin
Limb threatening :Limb threatening :
Broad spectrum : eg clindamycin+3Broad spectrum : eg clindamycin+3rdrd g ceph. g ceph.
clindamycin+ciprofluxacinclindamycin+ciprofluxacin
Ampicillin-sulbactamAmpicillin-sulbactam
Surgical managementSurgical management
UnroofingUnroofing
ProbingProbing
Debridement and drainage promptly if :Debridement and drainage promptly if :
-deep ulcers extending to subcutan.-deep ulcers extending to subcutan.
-deep tissue necrosis-deep tissue necrosis
-suppuration-suppuration
Amputation Amputation
Other measuresOther measures
Bed restBed rest
ElevationElevation
Control of diabetesControl of diabetes
Prevention Prevention
Tight glycemic controlTight glycemic controlExamination of the footExamination of the footAvoid extreme bath water temperatureAvoid extreme bath water temperatureAvoid foot soaksAvoid foot soaksDry the foot thoroughly after bathDry the foot thoroughly after bathTrim the nails correctlyTrim the nails correctlyTreat tinea pedis promptlyTreat tinea pedis promptlySelection of appropriate footwearSelection of appropriate footwear