A 40-year-old woman cuts her finger while cooking in her kitchen. Two days later she becomes rapidly ill with fever and shaking chills. Her hand becomes painful and mildly erythematous. Later that evening her condition deteriorates as the erythema progresses and the hand becomes dusky red. Bullae and decreased sensation to touch develop over the involved hand. What is the most important next step in the management of this patient?
The striking features of this infection are its rapid onset and progression to a cellulitis characterized by dusky dark-red erythema, bullae formation, and anesthesia over the area. The patient is acutely ill with fever, tachycardia, and other evidence of systemic inflammatory response syndrome (SIRS). These are clues to necrotizing fasciitis, a rapidly spreading deep soft tissue infection. The organism, usually Streptococcus pyogenes, reaches the deep fascia from the site of penetrating trauma. Prompt surgical exploration down to fascia or muscle may be lifesaving. Necrotic tissue is Gram-stained and cultured-streptococci, staphylococci, mixed anaerobic infection, or clostridia are all possible pathogens. Antibiotics to cover these organisms are important but not as important as prompt surgical debridement. Acute osteomyelitis is considered when cellulitis does not respond to antibiotic therapy but would not present with this rapidity.
Surgical consultation and exploration of the wound
Treatment with clindamycin for mixed aerobic-anaerobic infection
Treatment with penicillin for clostridial infection
Vancomycin to cover community-acquired methicillin-resistant Staphylococcus aureus (CA- MRSA)
Infection