• Necrotizing fasciitis: skin/soft tissue infection (SSTI) extending beyond epidermis/dermis/fat into fascia +/- muscle --> Poly- or mono-microbial (GAS, S. aureus, V. vulnificus-->immunocompromised/iron overload, C. perfringens-->myonecrosis) 
  • Red, tender, indurated w/ “pain out of proportion,” to other findings --> crepitus late and ominous
  • LRINEC score (CRP, WBC, Hgb, Na, Cr, glucose) – sensitivity limited (80%)
  • Imaging more sensitive: CT (subcutaneous air), MRI (fascial necrosis)
  • Empiric abx: Vanc/Linezolid + Pip-Tazo/Cefepime+Flagyl/Meropenem, Clindamycin + PCN if suspect GAS or Clostridia
  • Early surgical consult based on clinical suspicion --> definitive dx and treatment is debridement
  • Streptococcal toxic shock syndrome: typically associated w/ GAS SSTI (but 50% no clear portal of entry) –-> consider with septic shock and no obvious source, consider IVIG in addition to abx
  
  

  Posted 05/29/16 03:37:52 PM by Matthew Cummings

• Sepsis-3 definitions (Feb 2016): re-conceptualize sepsis as infection-related organ damage (SOFA), thus “severe sepsis”  no longer included
  • Sepsis = 2/3 qSOFA (HAT): Hypotension (SBP<100), AMS (GCS<15), Tachypnea (RR>22)
  • Septic shock = Sepsis + persistent hypotension (MAP<65) despite volume resuscitation (typically 20-30cc/kg) AND lactate ≥ 2 --> in-hospital mortality 40%
  
  

  Posted 05/29/16 03:39:00 PM by Matthew Cummings

• Resuscitation fluid: colloid vs. crystalloid
  • SAFE (2004): 4% albumin vs. NS in ICU patients --> no difference in all-cause mortality, non-significant trend toward improved mortality w/ albumin in severe sepsis, follow-up meta-analysis conflicting
  • SPLIT (2015): plasmalyte (balanced crystalloid) vs NS in SICU patients --> no difference in AKI or mortality (but low volumes given—median 2L)
  
  

  Posted 05/29/16 03:39:45 PM by Matthew Cummings

• For further reading...

   LRINEC score for diagnosis of necrotizing SSTI
  Necrotizing SSTI: clinical review
  2016 Sepsis-3 definitions (JAMA)
  SAFE trial (NEJM 2004)
  SPLIT trial (JAMA 2015)
  
  

  Posted 05/29/16 03:44:48 PM by Matthew Cummings

Created by Christopher Kelly

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