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(Individual Fields): Skin and Soft Tissue Infections View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector J Infect Chemother (2011) 17 (Suppl 1):72–76 DOI 10.1007/s10156-010-0143-8 GUIDELINES Chapter 2-5-3a. Anaerobic infections (individual fields): skin and soft tissue infections Ó Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases 2011. Open access under the Elsevier OA license. Introduction Necrotizing fasciitis is described in detail in other sections. The skin and underlying soft tissues are comprised of the epidermis (in external contact), dermis, subcutaneous fat Classification (adipose) tissue, fascia and muscles. Since anaerobes are bacteria that grow in oxygen-free (anaerobic) environ- Infection with gas-generating anaerobes (gas gangrene) ments, as to skin and soft tissue infections, these bacteria are involved in infections of fascia and muscle at deep sites Gas gangrene is classified into infections with Clostridium of the skin, where oxygen concentrations are lower than in (clostridial type) and those with bacteria other than superficial sites. Clostridium (non-clostridial type) [2]. The frequency of clostridial gas gangrene was previously high, but in recent years that of non-clostridial gas gangrene has tended to Pathogenesis increase [3]. No definite systematic classification of skin and soft tissue Clostridial gas gangrene This disease is a clostridial infections with anaerobic bacteria has yet been established. infection with gas-generating clostridia, and is also called In a narrow sense, however, these infections are classified ‘‘clostridial myonecrosis’’ [4]. There are 6 species of into two types according to the presence/absence of aerosis, causative bacteria: C. perfringens (Welch bacillus), i.e., gas gangrene and necrotizing fasciitis. The former C. novyi, C. histolyticum, C. sporogenes, C. septicum and condition is classified into infection with Clostridium C. fallax. The incidence of infection with C. perfringens is (clostridial type) versus bacteria other than Clostridium the highest (80–95%) [2]. (non-clostridial type) according to causative bacteria [1]. With regard to predisposing factors, the majority of Necrotizing fasciitis is classified into type I (polymicrobial these diseases are due to trauma; the disease manifests necrotizing fasciitis), i.e., mixed infections with anaerobic secondary to an operative, dermal sutures removal or bacteria, and type II due to group A b-hemolytic Strepto- contaminated wound, and also after tonsillectomy or coccus (Table 1). In actuality, there are some cases with abortion [3]. The latent period is 6 h to 2 days. The com- both gas gangrene and necrotizing fasciitis (double cases). mon sites of occurrence are the lower extremities. These The main causative bacteria are C. perfringens, Pepto- infections can also develop in the upper extremities, gluteal streptococcus anaerobius and Bacteroides fragilis. Cul- region, external pudendal region and the neck. tures yielding a single type of anaerobic bacteria are rare. Clinical symptoms include severe pain at the affected Genus Staphylococcus and genus Streptococcus show site as a local finding, redness, swelling, dark purple dis- symbiosis with anaerobic bacteria, and mixed infection of coloration, necrosis, fluctuation and blistering. Subcutane- either genus Staphylococcus or genus Streptococcus with ous crepitation is palpable. When gas is present at a anaerobes occurs in most cases. shallow skin site, rattles and fine crackles are recognizable. 123 J Infect Chemother (2011) 17 (Suppl 1):72–76 73 Table 1 Classification of skin and soft tissue infections with anaerobic bacteria Gas gangrene Necrotizing fasciitis Clostridial Non-clostridial Type I (polymicrobial Type II (streptococcal fasciitis) gangrene) Causative bacteria Mixed infections with Mixed infections with Bacteroides Obligate and facultative Group A b-hemolytic Clostridium species and species, Escherichia coli, anaerobes Streptococcus other bacteria Streptococcus species, etc., which include anaerobic bacteria Underlying diseases Trauma (contaminated Diabetes mellitus in many cases Diabetes mellitus, Absence of underlying wound, etc.) in most cases obesity, alcoholism, diseases in many cases etc. Progression of Rapid Slow Slow Rapid symptoms Inflammatory tissue Myositis, muscular necrosis Fascia, skin and subcutaneous tissue Fascia, muscles Skin and subcutaneous morphology tissue, fascia, muscles Dermal symptoms Local pain, redness, Local pain, redness, swelling, Local pain, redness, Marked edema, marked swelling, blister blister formation, dark purple swelling, blister erythema, blister, formation, discoloration, necrosis, and formation, dark purple hemorrhage, well- dark purple discoloration, fluctuation discoloration and demarcated necrosis, necrosis, and fluctuation necrosis ulcer Fine crackles and ++ -- crepitation Properties of pus/ Serous, smell of putrid flesh Purulent, putrid smell Purulent, malodorous (+) Serous, malodorous (-) malodorous Bacterial microscopic Gram-positive bacilli Gram-negative bacilli and Gram- Gram-positive cocci Gram-positive cocci findings positive cocci Blood examination Anemia, jaundice, General inflammatory findings, General inflammatory General inflammatory and hemoglobinuria, elevated Diabetes mellitus findings findings, elevated anti- urinalysis findings creatine phosphokinase streptolysin O (ASO) (CPK) X-ray findings Aerosis shows feathering Image of subcutaneous aerosis Gas (-) Gas (-) pattern in the muscle layer on imaging Hyperbaric oxygen Markedly effective Ineffective Ineffective Ineffective therapy When the wound is incised, serous and/or bouillon-like pus To investigate causative bacteria, Gram staining and is recognized. It has a specific strong putrid flesh smell. microscopy of smear preparations from pus and necrotic Remarkable generalized symptoms, as follows, are tissue must be conducted immediately as bacteriological associated with this disease: hyperthermia, arthralgia, tests. The presence of spores with Gram-positive bacilli muscle pain, nausea/vomiting, general malaise, delirium strongly suggests the clostridial type. Since anaerobic and shock. The clostridial type produces exotoxins leading culture takes several days, treatment should be started early to thrombus formation, and can cause disseminated intra- without waiting for culture results. vascular coagulation (DIC) and shock. Some reports have shown the mortality rate to be 7–25% On examination, gas bubbles in tissue is demonstrated [2, 4]. by X-ray or computed tomography (CT). Gas bubbles in the deep muscle layer produces a feather-like invasion Non-clostridial gas gangrene This is gas gangrene due to pattern on X-ray images [2]. Clinical laboratory data show non-clostridial infections with anaerobes. The causative leukocytosis with a nuclear shift to the left, extremely bacteria are obligate anaerobes including B. fragilis, increased C-reactive protein (CRP), increased blood sedi- Porphyromonas asaccharolytica, Peptostreptococcus an- mentation, and liver dysfunction. The spread of inflam- aerobius and Eggerthella lenta. In mixed infections with mation from fascia to muscles lead to increasing CPK or facultative anaerobes, Streptococcus pyogenes, Escherichia aldorase value, and sepsis, DIC and shock may develop coli, Klebsiella species, Proteus species and Staphylococ- from renal failure due to rhabdomyolysis [5]. cus aureus are included. 123 74 J Infect Chemother (2011) 17 (Suppl 1):72–76 Diabetes mellitus is associated with diseases due to Anaerobic infections without characteristic gas generation these pathogens in many cases, with a frequency of 60% among all cases. Other conditions associated with these Necrotizing fasciitis (for details, refer to other sec- pathogens include decubitus ulcers, carcinomas, pilonidal tions) This is the most serious infection leading to sinus and hidradenitis suppurativa [6]. These infectious necrosis of the skin and soft tissue with cardiovascular diseases also develop in many patients with liver disturbances. It is classified into type I (polymicrobial cirrhosis. fasciitis: causative bacteria are obligate and facultative The local findings and general symptoms are generally anaerobes) and type II [streptococcal gangrene: severe similar to those of clostridial gas gangrene; the disease infection with group A b-hemolytic Streptococcus leading spreads rapidly to reach the deep fascia. Superficial to sudden septic shock, DIC, adult respiratory distress swelling, fine crackles and crepitation manifest. When the syndrome (ARDS), and multiple organ failure] [1, 8]. wound is incised, gas bubbles are revealed. The discharge obtained by incision and drainage is purulent. In the case of infection with B. fragilis, the discharge smells like Causative bacteria feces. In the case of infection with P. anaerobius, the discharge is a yellowish pus which smells like fetid mud The main causative bacteria of skin and soft tissue anaer- [3]. obic infections are listed in Table 2. Examination findings of the disease are also similar to Bacteroides species includes small anaerobic Gram- those for clostridial gas gangrene, but gas bubbles rarely negative bacilli. B. fragilis is an anaerobe with relatively spreads to muscles in non-clostridial gas gangrene. Mixed high aerotolerance, and even when left untreated for infections with Streptococcus species may lead to the 3 days, some cells remain alive [7]. This resistance to rapid spread of phlegmon and cause streptococcal oxygen (the aerotolerant state) is
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