Skin and Soft Tissue Infections - Incision, Drainage, and Debridement Background 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. The various types of SSTIs, listed according to clinical presentation and anatomic location, include the following: Impetigo Folliculitis Furuncles Carbuncles Erysipelas Cellulitis Necrotizing fasciitis, also known as hemolytic streptococcal gangrene, Meleney ulcer, synergistic gangrene, and Fournier gangrene (when localized to the scrotum and perineal area) Pyomyositis 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) Streptococcus pyogenes 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) Malnutrition. simple abscesses. Early diagnosis and intervention may save a life. These infections pose little risk to life and limb. Bacteroides. inflammatory infection that is located in the deep fascia and is associated with secondary necrosis of the subcutaneous tissues. infected ulcers. Predisposing factors Factors predisposing to the development of SSTIs include the following: Breach in the epidermis Dry and irritated skin Immunocompromised status . rapidly spreading. The inflammation of the deep fascia causes thrombosis of the dermal vessels. Complicated SSTIs include complicated abscesses. Necrotizing fasciitis is a progressive. infections in diabetics. Complicated SSTIs involve the invasion of deeper tissues and typically require significant surgical intervention. SSTI may be divided into the following categories: Uncomplicated SSTI Nonnecrotizing complicated SSTI Necrotizing fasciitis Uncomplicated SSTIs include superficial cellulitis. These infections respond well to either source control management (ie. folliculitis. streptococci. AIDS Chronic venous insufficiency Chronic lymphatic insufficiency . furunculosis. The response to therapy is often complicated by underlying disease states. and minor wound infections.or life-threatening. and deep-space wound infections.Mixed infection with both aerobes (eg. diabetes mellitus. It is imperative to distinguish necrotizing infections from nonnecrotizing infections. staphylococci. burns. or aerobic gram-negative bacilli) and anaerobes (eg. and it is this thrombosis that is responsible for the secondary necrosis of the overlying subcutaneous tissue and skin. They are often limb. or Clostridium) Monomicrobial necrotizing fasciitis: S pyogenes Classification of SSTIs For the purposes of this article. infected burn wounds. delayed diagnosis and treatment may lead to loss of a limb or a life. drainage or debridement) or a simple course of antibiotics. hypoproteinemia. Peptostreptococcus. Polymicrobial necrotizing fasciitis . and alternatives of the procedure. a staged debridement should be planned to minimize damage to healthy tissue. Patient Education and Consent Consent should be obtained from the patient or family member. . Make sure that they have an understanding about the procedure so they can make an informed decision. Ideally. If possible. however. use of ultrasound when possible or indicated. the procedure may not be successful (the abscess may not be completely drained. Necrotizing fasciitis is a surgical emergency. Any ulcer covered with dead and necrotic tissue must be debrided to promote growth of healthy granulation tissue and healing. Preprocedural Planning Controlling the source of infection is the key to management of skin and soft-tissue infections (SSTIs) because it is the fastest way of decreasing the bacterial load. There should be no loose undermined skin edges at the end of surgical debridement. endocarditis). the direction of the incision should be in line with the natural skin crease. additional care should be taken in making the incision. and blunt dissection should be used instead to enter the abscess cavity. adequate analgesia. Any necrosed or unhealthy skin on the roof of the abscess should be excised completely. the risks. use of antibiotics when indicated). Allow the patient the opportunity to ask any questions and address any concerns they may have. must be drained for complete resolution. However. The patient should also be counseled that even if there are no complications. Chronic neuropathy Indications Any abscess. However. The aim of debridement is to create an acute wound milieu so as to trigger the body’s natural wound healing mechanisms and thereby promote healing. however small. overzealous debridement should be avoided in nonnecrotizing SSTIs. and debridement of SSTIs. the incision should be made at the most prominent part. stabilization to render him or her fit for anesthesia should be carried out before these procedures are undertaken. Contraindications There are no absolute contraindications for incision. If the patient's physical condition is compromised. Debridement should be done till healthy dermal bleeding is seen on the edges of the skin. early surgical treatment optimizes outcomes for these patients. if there are any major vessels or nerves in the area. additional surgery may be necessary). and injury of local nerves. The reason the procedure is being performed (suspected diagnosis). Technical Considerations In the drainage of an abscess. Source control is achieved by means of pus drainage and debridement (see Technique). a dependent incision should not be made if a tubercular etiology is suspected. dissemination of infection (sepsis. A bold incision must be made that goes all the way into the abscess cavity. Discuss how these risks can be avoided or prevented (eg. and the risks and benefits of not undergoing the procedure. drainage. The patient should be counseled about the risks of bleeding (damage to adjacent blood vessels). the risks and benefits of the alternative procedure. benefits. it should be made in a dependent area. FDA-approved antibiotics for the treatment of acute bacterial skin and skin structure infections include oritavancin (Orbactiv). Patients with relatively small abscesses usually do not require any antibiotics.In addition to surgical management of an SSTI. The following are indications for IV antibiotics: A severe soft-tissue infection is limb. selected investigations. so this should be considered in larger abscesses or those with significant associated inflammation. may require the following tests: Blood culture and drug susceptibility Complete blood cell (CBC) count with differential Creatinine level Bicarbonate level Creatine phosphokinase level C-reactive protein level Additional investigations may be indicated. Laboratory tests Patients with uncomplicated SSTIs usually do not require any investigations and need not be hospitalized. depending on the severity of systemic toxicity. antibiotic therapy. patients with symptoms and signs of systemic toxicity. Streptococcus pyogenes. antibiotics may hasten the resolution of an abscess after drainage. among others. In the setting of systemic disease or an immunocompromised host. However. or both may be indicated..or life-threatening The signs and symptoms of systemic illness are present The patient is immunosuppressed The patient is at the extremes of age Empirical antimicrobial therapy is administered as follows: Semisynthetic penicillins or second-generation cephalosporins are given to cover S aureus Site-specific antibiotics are given to cover indigenous organisms Appropriate antibiotics are given to cover methicillin-resistant S aureus (MRSA) if suspected Broad-spectrum antibiotics are given to patients with complicated SSTIs and immunocompromised status After identification of the organism or organisms and confirmation of drug sensitivity. Antimicrobial therapy Uncomplicated SSTIs with no symptoms or signs of systemic involvement respond well to incision and drainage and appropriate wound care. see the following monographs: . including dosing. Streptococcus agalactiae. and Streptococcus anginosus group (includes Streptococcus anginosus. dalbavancin (Dalvance). evidence has shown that even in the absence of associated cellulitis. Streptococcus intermedius. For complete drug information. The extent of abscess must be confirmed and complete drainage ensured at the time of surgical exploration. blood and wound cultures are recommended. appropriate antimicrobials are started. and Streptococcus constellatus). depending on the severity of the infection. and tedizolid (Sivextro). such as tachycardia and hypotension. These agents are active against S aureus (including methicillin- susceptible S aureus and MRSA] isolates). However. Oral or intravenous (IV) antimicrobial therapy is then started empirically. 11 and 15 Curved artery forceps Plane and toothed thumb forceps Curette Metzenbaum scissors Sterile swab stick Electrocautery Saline Hydrogen peroxide Patient Preparation Patient preparation includes adequate anesthesia and appropriate positioning. Anesthesia for incision and drainage is as follows: General anesthesia: This used for large and deep abscesses to facilitate complete and thorough drainage. and the anesthetic is infiltrated subcutaneously into the dome of the abscess to achieve anesthesia of the skin to enable painless skin incision. Regional anesthesia: This can be used for large and deep abscesses if patient cooperation can be ensured. Anesthesia for debridement is as follows: General anesthesia: Because debridement is a very painful procedure. anesthetizing the abscess cavity is not very effective. Local anesthesia: The overlying skin is anesthetized via a 26-gauge needle. Equipment The equipment required for incision. Nos. Positioning The patient is positioned in accordance with the location of the lesion. Whichever position is chosen should afford the surgeon easy access to the lesion and should be comfortable for the patient. Field block: This is used for small abscesses. and debridement is the basic surgical set. see Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. because the local anesthetic functions poorly in the acidic environment of the abscess. For the full guidelines. drainage. which includes the following: Sponge-holding forceps Surgical blade. Regional anesthesia: This may be used when general anesthesia is not desirable and patient cooperation can be ensured. Oritavancin Dalbavancin Tedizolid Guidelines The Infectious Diseases Society of America updated their guidelines for the diagnosis and management of SSTIs in 2014. . and complete analgesia is essential for thorough debridement. Surgical debridement is usually done with the patient under general anesthesia. If used. After a few minutes. but this must be done without damaging the underlying healthy tissue. subcutaneous tissue. It is then covered with a dry absorbent dressing that soaks up exudate and blood. . The abscess cavity is explored. Once the cavity is entered. a bold incision that cuts through the skin. a pus swab may be sent for microbiologic analysis if indicated. only skin and subcutaneous tissue are incised. The direction of the incision should parallel the natural skin creases as far as possible so as to prevent unsightly scars. However. and an artery forceps with a gauze piece wrapped around its tip is used to break up all the loculi and drain all the pus pockets. debris. however. packing should be inserted loosely. The slough over the lesion is then slowly excised off the underlying healthy tissue with a scalpel or scissors (see the images below). a simple dressing with gauze is sufficient. then packed with gauze or surgical sponge to achieve hemostasis. smaller areas of dead tissue can be excised using a curette. incision and drainage is carried out in the following manner. the packing is taken out. Incision and Drainage After proper positioning and anesthesia (see Periprocedural Care). When healthy granulation tissue is seen in the cavity and no fresh exudate or pus is visible. and any active bleeding points are cauterized. The slough is excised until the wound starts bleeding. The use of wound packing is controversial but is not likely necessary. In areas where no important neural or vascular structures are expected to be present. The tourniquet is released. but local or regional anesthesia may be employed if the lesion is not very extensive. The margins of the wound are also freshened. and blood. a tourniquet may be used to minimize blood loss. The lesion is cleaned and draped. the incision is made at the dependent portion of the abscess. The abscess cavity is irrigated with saline solution to flush out all the pus. The same result may be achieved with the surgeon's gloved finger if the presence of a foreign body in the cavity can be ruled out. A skin incision is made with a No. in areas where important neurovascular structures are present. At this point. The abscess cavity is entered by insinuating a pair of blunt artery forceps or sinus forceps through a small opening in the deep fascia. then gradually opening the blades. If there is no obvious pus pointing or fluctuant area in the abscess. and deep fascia may be made to achieve entry into the abscess cavity. 11 or 15 surgical blade in the most prominent and fluctuant part of the abscess. pus is seen extruding through the opening. Debridement for Infected Ulcers and Gangrene Surgery is the most effective method of debridement. The dressing is changed after 24 hours and again every 24 hours thereafter until the wound is dry. a dependent incision should be avoided if a tubercular pathology is suspected. and any active bleeding points are cauterized or ligated. If debridement is being done on a limb. At each dressing. the wound is inspected for any new slough or pus formation. Debridement of venous ulcer on foot.Venous ulcer on foot. tulle gras). regular dressing changes follow at 24- hour intervals. The first dressing is changed after 24 hours. The raw area created by debridement is covered with a nonadherent dressing (eg. Once the wound is clean. Other methods of debridement Debridement methods that may be used as alternatives to surgical debridement include the following : Mechanical Chemical Autolytic Biological Ultrasonic . Repeated debridements may be necessary until the wound becomes clean and active infection is controlled by appropriate antibiotics. dressings may be changed at 36-hour intervals. Commercially available collagenase enzyme granules are sprinkled onto the wound daily until the wound is clear of necrotic tissue. Chemical debridement is performed by using certain enzymatic chemicals on the wound that cause lysis of the necrotic tissue in the wound. This is a very painful method and is not much favored. it peels the adherent necrotic tissue away from the healthy tissue. When the dry dressing is taken off. .Mechanical debridement is accomplished by using the wet-to-dry dressing method. The dressing is then allowed to dry on the wound over the following 24-36 hours. Regular dressings then follow. The wound is dressed with a wet dressing (usually gauze soaked in saline) covered with a dry dressing.