Infeccion tejidos blandos

Severe Sof t Tissue I nfe c tions
Lena M. Napolitano, MD, FACS, FCCP, FCCM
KEYWORDS     Skin infections  Soft tissue infections Necrotizing soft tissue infections  Abscess Drainage  Debridement  Methicillin-resistant S aureus Antimicrobial therapy

Skin and soft tissue infections (SSTIs) span a spectrum of clinical entities from limited cellulitis to rapidly progressive necrotizingfasciitis, which may be associated with septic shock or toxic shock syndrome.1,2 These SSTIs may result in critical illness and require management in the ICU.3 The complex interplay of environment, host, and pathogen is important to consider when evaluating SSTIs and planning therapy. The key to a successful outcome in caring for patients who have severe SSTIs is: Early diagnosis and differentiationof necrotizing versus non-necrotizing SSTI Early initiation of appropriate empiric broad-spectrum antimicrobial therapy with consideration of risk factors for specific pathogens and mandatory coverage for methicillin-resistant Staphylococcus aureus (MRSA). Source control of early SSTI (ie, early aggressive surgical intervention for drainage of abscesses and debridement of necrotizing soft tissueinfections) Pathogen identification and appropriate de-escalation of antimicrobial therapy In addition, appropriate critical care management, including fluid resuscitation, organ support, and nutritional support are necessary components of treatment of severe SSTIs.
EARLY DIAGNOSIS AND DIFFERENTIATION OF NECROTIZING VERSUS NON-NECROTIZING SKIN AND SOFT TISSUE INFECTIONS Classification of Skin andSoft Tissue Infections

The US Food and Drug Administration (FDA) classifies SSTIs into two broad categories for the purpose of clinical trials evaluating new antimicrobials for the treatment of SSTIs: uncomplicated and complicated (Box 1). Uncomplicated SSTIs include superficial infections such as cellulitis, simple abscesses, impetigo, and furuncles. These infections can be treated byantibiotics or surgical incision for drainage of
Division of Acute Care Surgery, (Trauma, Burns, Critical Care, Emergency Surgery), Department of Surgery, University of Michigan Health System, Room 1C340A-UH, 1500 E. Medical Center Drive, SPC 5033, Ann Arbor, MI 48109-5033, USA E-mail address: lenan@umich.edu Infect Dis Clin N Am 23 (2009) 571–591 doi:10.1016/j.idc.2009.04.006 0891-5520/09/$ – see frontmatter ª 2009 Published by Elsevier Inc. id.theclinics.com

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Box 1 Classification of severe skin and soft tissue infections by the US Food and Drug Administration Uncomplicated Superficial infections, such as: Simple abscesses Impetiginous lesions Furuncles Cellulitis Can be treated by surgical incision alone Complicated Deep soft tissue, requires significant surgicalintervention Infected ulcers Infected burns Major abscesses Significant underlying disease state that complicates response to treatment Data from http://www.fda.gov/ohrms/dockets/98fr/2566dft.pdf. Accessed April 17, 2009.

abscess alone. In contrast, complicated sSTIs include deep soft tissue infections that require significant surgical intervention, such as infected ulcers, infected burns, and majorabscesses, Additionally, these patients also have significant underlying comorbidities (ie, disease states that complicate [and usually delay] response to treatment). Complicated SSTIs are a significant clinical problem, in part related to the increasing resistance of infecting bacteria to current antibiotic therapies. Uncomplicated SSTIs are associated with low risk for life- or limb-threateninginfection. Patients who have uncomplicated SSTIs can be treated with empiric antibiotic therapy according to likely pathogen and local resistance patterns. Complicated SSTIs are associated with high risk for life- or limb-threatening infection. In patients who have complicated SSTIs, it is of paramount importance to initiate appropriate and adequate broad-spectrum initial empiric antimicrobial...