Complicated skin, skin structure and soft tissue infections - are we threatened by multi-resistant pathogens?

Abstract

Tissue infections or skin, skin structure, and deep seated soft tissue infections are general terms for infections of the entire skin layer including the subcutaneous and muscle tissue layers and their respective fascia structures. Infections of the different mediastinal fascias (mediastinitis) and retroperitoneal fascia infections also belong to this category. Due to the variability of their clinical presentation, skin and soft tissue infections can be classified according to different features. The following aspects can be used for classification: - anatomical structures, - pathogens, - necessity for urgent treatment, - extent of infection. - The incidence of skin and soft tissue infections in which MRSA (methicillin-resistent Staphylococcus aureus) is involved has been steadily increasing over the past 15 years. These wounds should be treated according to the same open treatment principles as other infected wounds. Since these infections are often superficial contaminations, antibiotic therapy is not indicated. If systemic infection occurs in form of MRSA sepsis, antibiotic therapy is indicated. - Several recent reports identified MRSA as the leading pathogen in SSTIs. It also causes 20% to 50% of diabetes-associated foot infections in several countries and is associated with worse outcomes than other pathogens.

Figure 1

Severe perianal acne inversa (hidradenitis suppurativa). This disease may lead to incontinence without surgical intervention with sanitation of the perianal region.

Figure 2

32 year old intravenous drug abuser; multipe scars on the right leg; two acute inflammations on the left lower extremity.

Figure 3

65 year old women: insulin dependent diabetes mellitus for (!!!) 38 years. Inflammation and swelling of the foot. Compartment syndrome with intramuscular pressure of 48 mm Hg. Without immediate surgical intervention an amputation will be imperative.

Figure 4a

72 year old women with a complicated intra abdominal infection after sigmoidectomy with anastomotic insufficiency followed by a Hartmann procedure. After 4 weeks on ICU the patient develloped a MRSA infection of the open abdominal wound.

Figure 4b

Closure of the open abdomen by a meshgraft; persisting infection with MRSA for 6 month.

Figure 4c

Six weeks post reanastomosis of the colon (descend -rectostomy) and total closure of the abdominal wall. After this procedure and healing of the surgical wound no MRSA could be identified.

Figure 5

40 year old women with encephalitis disseminata and anti TNF α therapy. After shaving of the axilla she develloped a fulminant septic shock with MOF, due to GAS bacteriemia. The black livid efflorescence looks like a map showing the typical picture of necrotising fasciitis. The progress of the skin alteration occured within 2 -3 hours.