Skin and Soft Tissue Infections - Incision, Drainage, and Debridement
- Author: Hemant Singhal, MD, MBBS, FRCS(Edin), FRCSC; Chief Editor: Erik D Schraga, MD more...
Skin and soft tissue infections (SSTIs), which include infections of skin, subcutaneous tissue, fascia, and muscle, encompass a wide spectrum of clinical presentations, ranging from simple cellulitis to rapidly progressive necrotizing fasciitis. Diagnosing the exact extent of the disease is critical for successful management of a patient of soft tissue infection.[1, 2, 3, 4, 5]
The various types of SSTIs, listed according to clinical presentation and anatomic location, include the following:
Necrotizing fasciitis, also known as hemolytic streptococcal gangrene, Meleney ulcer, synergistic gangrene, and Fournier gangrene (when localized to the scrotum and perineal area)
SSTIs may be caused by any of a formidable number of pathogenic microorganisms, and they may be either monomicrobial or polymicrobial. The following are the most important pathogens:
Staphylococcus aureus (the most common pathogen)
Site-specific infections - Indigenous organisms (eg, gram-negative bacilli in perianal abscesses)
Immunocompromised hosts and complicated SSTIs - Multiple organisms or uncommon organisms (eg, Pseudomonas aeruginosa, beta-hemolytic streptococci, Enterococcus)
Polymicrobial necrotizing fasciitis - Mixed infection with both aerobes (eg, streptococci, staphylococci, or aerobic gram-negative bacilli) and anaerobes (eg, Peptostreptococcus, Bacteroides, or Clostridium)
Monomicrobial necrotizing fasciitis: S pyogenes
Classification of SSTIs
For the purposes of this article, SSTI may be divided into the following categories:
Nonnecrotizing complicated SSTI
Uncomplicated SSTIs include superficial cellulitis, folliculitis, furunculosis, simple abscesses, and minor wound infections. These infections respond well to either source control management (ie, drainage or debridement) or a simple course of antibiotics. These infections pose little risk to life and limb.
Complicated SSTIs involve the invasion of deeper tissues and typically require significant surgical intervention. The response to therapy is often complicated by underlying disease states. Complicated SSTIs include complicated abscesses, infected burn wounds, infected ulcers, infections in diabetics, and deep-space wound infections. They are often limb- or life-threatening.
Necrotizing fasciitis is a progressive, rapidly spreading, inflammatory infection that is located in the deep fascia and is associated with secondary necrosis of the subcutaneous tissues. The inflammation of the deep fascia causes thrombosis of the dermal vessels, and it is this thrombosis that is responsible for the secondary necrosis of the overlying subcutaneous tissue and skin.
It is imperative to distinguish necrotizing infections from nonnecrotizing infections. Early diagnosis and intervention may save a life; delayed diagnosis and treatment may lead to loss of a limb or a life.
Factors predisposing to the development of SSTIs include the following:
Breach in the epidermis
Dry and irritated skin
Immunocompromised status - Malnutrition, hypoproteinemia, burns, diabetes mellitus, AIDS
Chronic venous insufficiency
Chronic lymphatic insufficiency
Any abscess, however small, must be drained for complete resolution. Any ulcer covered with dead and necrotic tissue must be debrided to promote growth of healthy granulation tissue and healing. Necrotizing fasciitis is a surgical emergency; early surgical treatment optimizes outcomes for these patients.
There are no absolute contraindications for incision, drainage, and debridement of SSTIs. If the patient's physical condition is compromised, stabilization to render him or her fit for anesthesia should be carried out before these procedures are undertaken.
In the drainage of an abscess, the incision should be made at the most prominent part. If possible, it should be made in a dependent area; however, a dependent incision should not be made if a tubercular etiology is suspected. Ideally, the direction of the incision should be in line with the natural skin crease.
A bold incision must be made that goes all the way into the abscess cavity. However, if there are any major vessels or nerves in the area, additional care should be taken in making the incision, and blunt dissection should be used instead to enter the abscess cavity. Any necrosed or unhealthy skin on the roof of the abscess should be excised completely.
Debridement should be done till healthy dermal bleeding is seen on the edges of the skin. There should be no loose undermined skin edges at the end of surgical debridement. However, overzealous debridement should be avoided in nonnecrotizing SSTIs; a staged debridement should be planned to minimize damage to healthy tissue.
Abrahamian FM, Talan DA, Moran GJ. Management of skin and soft-tissue infections in the emergency department. Infect Dis Clin North Am. 2008 Mar. 22(1):89-116, vi. [Medline].
Lopez FA, Lartchenko S. Skin and soft tissue infections. Infect Dis Clin North Am. 2006 Dec. 20(4):759-72, v-vi. [Medline].
May AK. Skin and soft tissue infections. Surg Clin North Am. 2009 Apr. 89(2):403-20, viii. [Medline].
Napolitano LM. Severe soft tissue infections. Infect Dis Clin North Am. 2009 Sep. 23(3):571-91. [Medline].
Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005 Nov 15. 41(10):1373-406. [Medline].
Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 5th ed. 2009.
De Waele JJ. Early source control in sepsis. Langenbecks Arch Surg. 2010 Jun. 395(5):489-94. [Medline].
Dryden MS. Complicated skin and soft tissue infection. J Antimicrob Chemother. 2010 Nov. 65 Suppl 3:iii35-44. [Medline].
Barclay L. IDSA: skin and soft tissue infections guidelines updated. Medscape Medical News. Available at http://www.medscape.com/viewarticle/827399. Accessed: June 26, 2014.
[Guideline] Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of america. Clin Infect Dis. 2014 Jul 15. 59(2):e10-52. [Medline]. [Full Text].
Sinha SN. Wound debridement: doing and teaching. Primary Intention. 2007 Nov. 15:162-4. [Full Text].
Hofman D. Autolytic debridement in venous leg ulcers. Available at http://www.woundsinternational.com/pdf/content_186.pdf.
Wong CH, Yam AK, Tan AB, Song C. Approach to debridement in necrotizing fasciitis. Am J Surg. 2008 Sep. 196(3):e19-24. [Medline].