Review
Rapidly progressive soft tissue infections

https://doi.org/10.1016/S1473-3099(05)70191-2Get rights and content

Summary

Skin and soft tissue infections are among the most common reasons for people to seek medical advice. They also represent one of the most common indications for antimicrobial therapy and account for approximately 7–10% of hospitalisations in North America. Although non-limb and non-life threatening infections may be treated on an out-patient basis with oral antibiotics, patients with more serious acute skin and soft tissue infections may require admission to hospital for management; this decision is especially true if the infection is rapidly progressive. We provide a concise overview of the differential diagnosis and approach to management of community-acquired rapidly progressive skin and soft tissue infections.

Introduction

Skin and soft tissue infections (SSTIs) account for approximately 7–10% of hospitalisations in North America.1, 2 There have been several excellent reviews of skin and soft tissue infections and their management. However, these reviews focus primarily upon classification systems, as well as diagnostic and therapeutic interventions for all the SSTIs, including the diabetic foot,2, 3, 4, 5, 6 but not specifically addressing those that are rapidly progressive. Thus, this overview will focus specifically upon rapidly progressive SSTIs. Infections caused by Staphylococcus aureus, particularly meticillin-resistant S aureus (MRSA), will be briefly addressed, as they have been reviewed elsewhere.2, 3, 7

Section snippets

Classification

The classification of SSTIs is complex. Some classification schemes have divided SSTIs into academic categories that may not be directly applicable at the bedside. However, a practical approach based on history and physical examination should be directed towards answering the following questions: “which organisms are likely to be involved?”, “what is the depth of the infection?”, and “is the infection life or limb threatening?”. The first question will guide empirical antimicrobial therapy. The

Pathophysiology

The skin and surrounding soft tissue is divided, from the most superficial to deeper structures, into the epidermis and dermis, the subcutaneous tissue (which contains vascular structures and nerves), and the fascia and muscle. Although any of these layers may be involved in the spectrum of SSTIs, the more severe infections tend to be associated with deeper tissue invasion. The portal of entry for microorganisms to gain access to the skin and soft tissue is most commonly trauma to the external

Community-acquired MRSA

S aureus is one of the most common causes of cellulitis. Cellulitis caused by S aureus can be difficult, if not impossible, to distinguish clinically from that caused by group A streptococcus, but it is usually associated with skin trauma, and is more likely to be bullous.2 If inadequately treated, local abscesses, necrotising fasciitis, or septicaemia may occur. As less than 5% of clinical isolates of S aureus are currently susceptible to penicillin because of the production of a

Conclusions

When a patient presents with a rapidly progressive SSTI, the potential consequences of the disease can be frightening. Clinicians must remember that only a limited number of common organisms can produce this entity. Clinically, it may be impossible to differentiate the aetiological agents responsible for the episode of rapidly progressive SSTI. Clues from the history, combined with characteristic clinical findings—eg, lesions with distinct raised borders or rapidly spreading crepitant

Search strategy and selection criteria

Data for this review were identified by searches of papers published in English on Medline, spanning the years 1975 through February 1, 2005 with the key words: “cellulitis”, “skin”, “soft tissue infection”, “rapidly progressive”, “rapidly spreading”, “rapid”, “necrotizing”, “fasciitis”, “myonecrosis”, “management”, and “treatment” in association with “group A streptococcus”, “Streptococcus pyogenes”, “Pasteurella”, “Clostridium”, “Aeromonas”, and “Vibrio”. Relevant references were also

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