The role of surgery in the management of septic shock—extra-abdominal causes of sepsis

AORN Journal,  Jan, 2007  by George H. Sakorafas,  Adelais G. Tsiotou,  Maria Pananaki,  George Peros

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Early administration of appropriate, high-dose antibiotic therapy is indicated for patients who have a serious, soft-tissue infection (eg, severe cellulitis, necrotizing fasciitis). When selecting antibiotics, health care providers should consider that most cases of necrotizing fasciitis represent polymicrobial infections involving gram-positive cocci (ie, usually Staphylococci), aerobic gram-negative bacilli, and anaerobes. High-dose penicillin; a broad-spectrum agent (eg, meropenem); and clindamycin are indicated in these situations. Clindamycin is the antibiotic of choice if the responsible microorganism is Clostridium species because clindamycin stops the production of toxin A. When initially selecting antibiotics for empiric antibiotic therapy, health care providers should consider it very probable that a complex infection is present if the

* patient has diabetes,

* patient is an illicit IV drug user, or

* infection has an abdominal presentation. (17,18)

Further antibiotic therapy should be based on culture results.

Recently, a particular form of severe soft-tissue infection (ie, idiopathic necrotizing fasciitis) has been reported. This infection is caused by group A Streptococci without an obvious point of entry and without a loss of skin continuity. (19,20) Most likely, these cases are due to hematogenous dissemination of Streptococci from an unknown source, probably from the oropharynx. (19,20)

FOURNIER'S DISEASE, Fournier's disease is a severe, necrotizing infection of the perineum caused by aerobic and anaerobic microorganisms (ie, polymicrobial synergistic infection). A characteristic finding is a black spot on the skin of the perineum that is observed early in the clinical course of the disease. As in necrotizing fasciitis, high fever, intense pain, and severe leukocytosis are typical. (21) Treatment for Fournier's disease is the same as for necrotizing fasciitis:

* wide surgical debridement with removal of necrotic tissues and

* appropriate antibiotic therapy.

When extensive debridement is deemed necessary, creating a proximal, diverting colostomy to divert feces will facilitate wound healing. (22)

PERIRECTAL ABSCESSES. Perirectal abscesses can be a source of infection that can remain undiagnosed in patients who have sepsis, particularly in patients with diabetes or in patients who are immunosuppressed (eg, patients receiving corticosteroids or chemotherapy). (21) Fluctuance, which is a characteristic finding on palpation indicating the presence of fluid (ie, pus) typically observed in abscesses, may be absent. Pain on defecation and local induration are useful findings for diagnosis. Needle aspiration usually yields a purulent material, thereby establishing the diagnosis. Optimal management of perirectal abscesses consists of surgical drainage under general or regional anesthesia. Antibiotics should be administered only as a supplement to the surgical therapy. Treatment failure may be observed when

* perirectal abscesses remain undiagnosed;