A presentation designed for in hospital teaching

1. The operative approach

2.  Simple focal infections
 Impetigo contagiosa – minor skin abrasion – normally caused by S aureus or S pyogenes
 Folliculitis – staphylococcal pyodermas of the hair follicles which may coalesce to form
carbuncles
 Necrotising focal infections
 Bacterial synergistic gangrene – can be wet or gas gangrene
 Fournier’s gangrene (located in the scrotum or perineum) – this is a location-specific
form of necrotising fasciitis
 Toxic non-necrotising focal infections
 Staph scaled skin syndrome
 Toxic shock syndrome
Ref for the following slides: Stevens, D.L., et al., Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infections
diseases society of America. CID, 2014. 59: p. 10-50.

3.  Diffuse non-necrotising infection
 Cellulitis and erysipelas
 Diffuse necrotising cellulitis
 Pyomyositis
 Abscesses

5.  Simple abscesses
 Incision to known area of abscess
 Along langer’s lines where possible
 Remove all infected tissue
 Generally not for primary closure
 Complex infections such as
carbuncles
 Excise whole area of infection
 Some evidence that skin grafts can be
done primarily however this is not
common practice
 Post-operative antibiotics do not affect
wound healing but may reduce rates of
recurrence in simple abscesses and
carbuncles

6.  Most breast abscesses develop as a
complication of lactational mastitis
 I&D yields lower recurrence rate BUT
results in
 scarring,
 structural damage,
 risk of milk fistula,
 painful breastfeeding,
 prolonged healing times,
 poor cosmesis
 Therefore US guided needle aspiration
+/- drain insertion is treatment of
choice in most cases
 Post acute infection, may be need for
excision of damaged/chronically
inflamed tissueRef:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3335354/pdf/brc-0007-0032.pdf
http://iahealth.net/breast-abscess-and-mastitis/
BMJ Best Practice
 Image redacted for uploaded edition
 Please google breast abscesses to
find your own!

7. Agostini, T., et al., Successful
combined approach to a severe
Fournier’s gangrene. Indian Journal of
Plastic Surgery, 2014. 41(1): p. 132-
136.
https://radiopaedia.org/articles/fournie
r-gangrene
https://www.researchgate.net/figure/Fo
urniers-gangrene-of-the-
scrotum_fig2_221915361
Recommended
reading!! 

8.  Three concentric zones of erythema,
cyanosis and necrosis at the site of
synergistic infection
 Often a small cut, bruise or abrasion
as the initial trigger
 Common skin bacteria with
superimposed (synergistic) bacteria
 C. perfringens creates gas gangrene
 Treatment is multimodal
 IVF
 Vasopressors if required
 Broad spectrum Abx covering gram
positive and gram negative as well an
anaerobic bacteria – e.g. vanc +
tazocin or vanc meropenem or vanc +
ceftriaxone + metronidazole or vanc +
ciprofloxacin + metronidazole
 Urgent debridement in theatre – down
to underlying healthy tissue. Any
plane that separates easily with blunt
dissection should be considered
involved
 Delayed reconstruction

9.  Many skin and soft tissue infections
can be managed conservatively
 Antibiotic use is generally to cover
common skin bacteria that have
breached the skin immune barrier
through minor trauma
 US-guided needle aspiration can be
used for breast abscesses
 UNLESS the abscess is >5cm in which
case I&D should be considered
 Incision and drainage is the
mainstay of treatment for skin
abscesses
 Excision is the mainstay of
treatment for carbuncles
 Antibiotics post-op help reduce risk
of recurrence
 Necrotising fasciitis and fournier’s
are surgical emergencies requiring
extensive debridement down to
healthy tissue (sometimes
amputation) as well as broad
spectrum antibiotics and IVF and
often vasopressor support