Treatment of Severe Skin and Soft Tissue Infections

A Review

Jason P. Burnham; Marin H. Kollef


Curr Opin Infect Dis. 2018;31(2):113-119. 

In This Article

Special Considerations

Unusual causes of SSTI are outside the scope of this review, as most are rare and not typically associated with severe illness. For additional information, see recent reviews on this subject.[19]

Immunocompromised Hosts

Immunodeficiency changes the physical examination findings of SSTI, the putative pathogens, and the diagnostic and treatment plans. The differential diagnosis for dermatologic findings in the immunocompromised host includes noninfectious causes and a broader range of infections, including invasive fungal, mycobacterial, and parasitic infections.[4,19] With a broader differential diagnosis and greater potential for decompensation, early dermatologic consultation for immunocompromised patients may be beneficial.[4,46] Dermatology consultation can improve the diagnosis of dermatologic findings in critically ill patients and reduce antimicrobial use.[46,47] Many dermatologic conditions mimic infection, for which dermatologist expertise can be helpful in distinguishing.[19,48]

All immunocompromised patients that are critically ill should undergo thorough cutaneous examination as immunosuppression tends to reduce physical exam findings of SSTIs. Immunosuppressed patients are more likely to have cutaneous dissemination of pathogens. A recent study showed that immunocompromised patients with S. pyogenes were more likely to have necrotizing fasciitis, septic shock, and die than immunocompetent patients.[49] Conversely, in a cohort of patients with S. aureus infections, some of which had SSTIs, immunocompromise was not a risk factor for mortality.[50]

When possible, reduction of immunosuppression should be considered for severe infections. For patients with febrile neutropenia, Multinational Association of Supportive Care of Cancer score is important for predicting complication rates.[51] In neutropenic patients, factors to consider when contemplating surgery are probable duration of neutropenia and severity of infection. Patients with shorter durations of neutropenia have a higher likelihood of recovering from surgical interventions and are likely better candidates for surgery. Management of necrotizing SSTIs in neutropenic patients is poorly studied, and treatment strategies should be individualized.