1.
Wound and soft tissue infections.
The main pathogens. Features of
laboratory diagnostics,
treatment.
Vinnitsa National Pirogov Memorial Medical University/
Department of microbiology

2.
Superficial cutaneous infection: Streptococci and
Staphylococcus aureus, including methicillin-resistant S.
aureus (MRSA)
Necrotizing infection:
Mixed infection of facultative gram-negative bacilli,
anaerobes, and gram-positive organisms
S.pyogenes and other group A streptococci,
Clostridium spp.
Vibrio spp.

3.
Impetigo
Impetigo is a superficial
crusting and at times bullous
infection of the skin; localized
progression into the dermis
leads to ecthyma.
• Mostly in children
• Causes: β-hemolytic
Streptococcus spp. and/or S.
aureus.

4.
Folliculitis, furuncle, carbuncle
Folliculitis is a localized
infection of hair follicles,
which can extend into
subcutaneous tissue,
resulting in furuncles.
These, in turn, may
coalesce, leading to
carbuncle formation.
Main causes:
S.epidermidis, S.aureus,
including MRSA

5.
Erysipelas, cellulitis
Erysipelas is a rapidly progressive
infection of the superficial dermis,
with sharp erythematous borders;
Cellulitis reflects deeper dermal
involvement.
Pathogens: Streptococcus spp.,
usually Streptococcus pyogenes,
S.equi. S. aureus rarely causes
erysipelas.
Most facial infections are attributed
to group A Streptococcus (GAS), with
an increasing percentage of lower
extremity infections being caused by
non-GAS.

6.
Abscess
A cutaneous abscess is an
infection characterized by a
collection of pus underneath a
portion of the skin.
Pathogens reflect flora of the
involved area (eg, S.
aureus and streptococci in the
trunk, axilla, head, and neck),
but methicillin-resistant S.
aureus (MRSA) has become
more common.

7.
Necrotizing fasciitis
Necrotizing fasciitis affects the soft tissue and fascia. Necrotizing infections are
polymicrobial with involvement of enteric flora including non-sporeforming anaerobs;
clostridial infections are very severe, sometimes fatal (gas gangrene), other pathogens may
also participate (Vibrio spp., Streptococcus pyogenes)

8.
• NO DELAY!
• Local surgical treatment (operative debridement) plus antiseptics
irrigation
• Recommended antibiotics are used parenterally (IV): main
regimen: Vancomycin plus clindamycin plus meropenem
• The initial empirical antibiotic regimen should comprise broad-
spectrum drugs including anti-MRSA and anti-Gram-negative
coverage.
• Daptomycin or linezolid are drugs of choice for empirical anti-MRSA
coverage. Alternatively, ceftaroline, telavancin, tedizolid, and
dalbavacin can be used . The choice of anti-Gram-negative
treatment should be based on local prevalence of ESBL-producing
Enterobacateriaceae and multidrug-resistant organisms (MDROs)
non-fermenters.
• Adjuvant hyperbaric oxygen therapy in patients with NSTI after
prompt debridement
• Intravenous immunoglobulin therapy at clostridial infection

9.
SSIs are defined as infections of skin or underlying soft
tissues at the surgical site, occurring within 30 days
following National Healthcare Safety Network (NHSN)
operative procedure in which an incision was closed
primarily.

10.
Classification
SSIs are classified as:
1. Superficial incisional
infection,
2. Deep incisional infection,
3. Organ space infection.
Superficial incisional infections
are the most common type of
SSIs.
Deep incisional and
organ/space are the types of
SSIs that cause the most
morbidity.
Organ space infections are not
genuine soft-tissue infections.

11.
Risk factors for SSIs
Patients factor
• Diabetes mellitus/perioperative
hyperglycemia
• Concurrent tobacco use
• Remote infection at time of surgery
• Obesity
• Low preoperative serum albumin
• Malnutrition
• Concurrent steroid use
• Prolonged preoperative stay
• Prior site irradiation
• Colonization with Staphylococcus
aureus (MSSA, MRSA)
Proceduralist factors
Surgical technique (poor hemostasis,
tissue trauma)
Lapses in sterile technique and asepsis
Glove micropenetrations
Procedural factors
• Shaving of site the night before
procedure
• Use of razor for hair removal
• Improper preoperative skin
preparation/use of non–alcohol-
based skin preparation
• Improper antimicrobial
prophylaxis (wrong drug, wrong
dose, wrong time of
administration)
• Failure to timely redose
antibiotics in prolonged
procedures
• Perioperative hypothermia
• Perioperative hypoxia

12.
• Avoid preoperative antibiotic use (excluding surgical
prophylaxis)
• Minimize preoperative hospitalization
• Treat remote sites of infection before surgery
• Avoid shaving or razor use at operative site
• Delay hair removal at operative site until time of surgery
and remove hair (only if necessary) with electric clippers
or depilatories
• Ensure timely administration (including appropriate
dose) of prophylactic antibiotics
• Consider elimination of Staphylococcus aureus nasal
carriage via decolonization techniques

13.
Class I: No signs of systemic toxicity No uncontrolled
comorbidities Can usually be managed with oral
antimicrobials on an outpatient basis
Class II: Systemically ill or Systemically well but with a co-
morbidity such as peripheral vascular disease, chronic
venous insufficiency or morbid obesity which may
complicate or delay resolution of their infection.
Class III: Infection in a patient with evidence of systemic
inflammatory response syndrome.
Class IV: Septic shock (Sepsis plus hypotension) or signs of
organ dysfunction.

14.
Class First line Allergy to penicillin MRSA suspected
Class I Flucloxacillin 1g orally clarithromycin 500mg
orally
doxycycline 100mg
orally
Class II Flucloxacillin 1g parenterally clarithromycin 500mg
parenterally
Vancomycin
Class III Flucloxacillin 2g parenterally
For immunocompromised:
Piperacillin-tazobactam IV
4.5g
Vancomycin
parenterally
Add oral ciprofloxacin
500mg for
immunocompromised
Vancomycin
parenterally
Add oral ciprofloxacin
500mg for
immunocompromised
Class IV Piperacillin-tazobactam
parenterally 4.5g plus
Vancomycin parenterally
Vancomycin plus oral
ciprofloxacin 500mg
plus oral metronidazole
400mg TDS
As first line

15.
Swab collection
Collect swab specimens before antimicrobial therapy where possible.
Specimens should be transported and processed as soon as possible.
The volume of the specimen influences the transport time that is acceptable.
Large volumes of purulent material maintain the viability of anaerobes for longer.
The recovery of anaerobes is compromised if the transport time exceeds 3 hr.
If processing is delayed, refrigeration is preferable to storage at ambient
temperature.
Delays of over 48hr are undesirable for best result outcome Pus swabs;
When using swabs, please sample the deepest part of the wound, or a
representative part of the lesion. If specimens are taken from ulcers, the debris on
the ulcer should be removed and the ulcer should be cleaned with saline.
Swabs should be placed in bacterial transport media. If a delay in transporting to the
laboratory is anticipated, please store at 4o c
A biopsy or, preferably, a needle aspiration of the edge of the wound should then be
taken.
A less invasive irrigation-aspiration method may be preferred.
Blood cultures should be taken for a line infection and for any Class III or IV infections

16.
Bite wounds
Bite wounds are common injuries caused
by a wide variety of domestic and wild
animals, as well as humans
Mammalian bites are typically colonised
by pathogens found in the oral cavities of
the offending animal.
These are a mixture of aerobic and
anaerobic micro-organisms including;
Streptococci, Staphylococci, Moraxella,
Neisseria. Fusobacterium, Bacteroides,
Porphyromonas, and Prevotella spp.
Pasteurella multocida is a Gram-negative
pathogen particularly prevalent in dog
(57%) and cat (75%) bites.
In cases of human bite wounds and
clenched fist wounds, where HIV and
Hepatitis B status is unknown, please
treat patients in line with the Trust’s PEP
policy.

17.
Prophylaxis with antimicrobials of mammalian bites is indicated in
the following circumstances:
1. all cat bites, animal bites to the hand, foot and face;
2. puncture wounds;
3. wounds requiring surgical debridement;
4. wounds involving joints, tendons, ligaments or suspected
fracture
5. Clenched-fist wounds (wound inflicted from a punch coming in
contact with teeth) Wounds that have undergone primary
closure
6. People who are at risk of serious wound infection e.g. diabetic,
cirrhotic, asplenic or immunocompromised patients
7. People with a prosthetic valve or prosthetic joint

18.
• Irrigate wounds with copious amounts of normal saline.
• Cautiously debride devitalized or necrotic tissue.
• Primary wound closure is not usually advocated; delayed primary closure or
allowing the wound to close by secondary intention is recommended.
• Loose approximation of wound edges with adhesive strips or sutures may be
necessary for selected, fresh, uninfected wounds. Closure of facial wounds may be
considered if coupled with copious irrigation and antimicrobial preemptive
therapy.
• Provide antimicrobial therapy for (1) moderate-to-severe injuries less than 8 hours
old, especially if edema or significant crush injury is present; (2) bone or joint
space penetration; (3) deep hand wounds; (4) immunocompromised patients
(including those with mastectomy, advanced liver disease, asplenia, or chronic
steroid therapy); (5) wounds adjacent to a prosthetic joint; and (6) wounds in close
proximity to the genital area. Early presenting (uninfected) wounds:
• Infected wounds: Cover Pasteurella (Eikenella in human bites), Staphylococcus,
Streptococcus, and anaerobes including Fusobacterium, Porphyromonas,
Prevotella, and Bacteroides spp. The following antimicrobials can be considered for
most terrestrial animal and human bites in adults:

19.
The following antimicrobials can be considered for most terrestrial animal
and human bites in adults:
• First choice: Amoxicillin/clavulanic acid with food.
• Penicillin allergy:
For adults: • Clindamycin plus either ciprofloxacin or levofloxacin orally daily
Alternative: Doxycycline or Moxifloxacin orally daily.
• In cases where intravenous antibiotics are deemed necessary, single
antimicrobial choices can include ampicillin/sulbactam, cefoxitin, ertapenem,
or moxifloxacin.
• Empirical regimens for marine- and freshwater-acquired infection should
also cover Vibrio and Aeromonas species, respectively, with agents such as
third-generation cephalosporins (e.g., cefotaxime) and fluoroquinolones.
Others:
TT is given intramuscularly if a person is not immune to tetanus
Rabies vaccine is given to those who is suspected for being bitten with rabid
or wild animal

20.
Burn wounds
• Burn wound infections usually are
polymicrobial. They can be
immediately colonized by Gram-
positive bacteria (Staphylococcus
spp., Streptococcus spp.) from the
patient’s endogenous skin flora or
the external environment.
• However, they can also be rapidly
colonized by Gram-negative
bacteria (Acinetobacter
spp.,Pseudomonas, enteric
bacteria) usually within a week of
the burn injury.
• Bacterial cultures can aid in the
selection of an appropriate
antibiotic, especially in cases of
bacterial drug resistance

21.
SSTIs encompass a variety of pathological conditions
ranging from simple superficial infections to severe
necrotizing infections. The multifaceted nature of these
infections has led to a collaboration among general and
emergency surgeons, intensivists, and infectious
diseases specialists, who have shared these clinical
practice recommendations.
Cited from: Sartelli, M., Guirao, X., Hardcastle, T.C. et al. 2018
WSES/SIS-E consensus conference: recommendations for the
management of skin and soft-tissue infections. World J Emerg
Surg 13, 58 (2018). https://doi.org/10.1186/s13017-018-0219-9

22.
• Mandell, Douglas and Bennett`s Infectious Diseases Essentials, [edited by ]
J.E.Bennett, R.Dolin, M.J.Blaser. -Elseiver, 2017. – 520 p.
• Practice Guidelines for the Diagnosis and Management of Skin and Soft
Tissue Infections: 2014 Update by the Infectious Diseases Society of
America/ Dennis L. Stevens, Alan L. Bisno, Henry F. Chambers, E. Patchen
Dellinger, Ellie J. C. Goldstein, Sherwood L. Gorbach, Jan V. Hirschmann,
Sheldon L. Kaplan, Jose G. Montoya, and James C.Wade/CID (2014):59 (15
July)
https://academic.oup.com/cid/article/59/2/e10/2895845
• Skin and Soft Tissue Infections (SSTI) Antibiotic Guidelines (Adult) Group
arrangements: Salford Royal NHS Foundation Trust (SRFT) Pennine Acute
Hospitals NHS Trust (PAT) Issue Date: 29/08/2019
• Sartelli, M., Guirao, X., Hardcastle, T.C. et al. 2018 WSES/SIS-E consensus
conference: recommendations for the management of skin and soft-tissue
infections. World J Emerg Surg 13, 58 (2018).
https://doi.org/10.1186/s13017-018-0219-9