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Skin and Soft Tissue Infections Among Cancer Patients

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Oncologic Critical Care

Abstract

Skin and soft tissue infections are commonly encountered in the oncologic patient admitted to the intensive care unit. We describe five groups of clinical syndromes:

  • Necrotizing soft tissue infections are characterized by a rapid and large-scale tissue destruction, usually accompanied by severe systemic toxicity. Necrotizing fasciitis (NF) affects the subcutaneous fat and the deep fascia. The infection can be polymicrobial (type I), associated with a breach of a mucosal barrier, or monomicrobial (type II), occurring after a skin penetration or spontaneously following blunt trauma. Given the lack of clinical suspicion, NF is frequently misdiagnosed as a simple cellulitis with devastating consequences. Early debridement and rapid onset of appropriate antibiotic therapy are essential to decrease its high morbidity and mortality.

  • Cellulitis, erysipelas, and skin abscess are common in patients who have undergone invasive surgery, lymphadenectomy, or recent bacteremia.

  • Perirectal infections are frequent in hematological cancer patients with prolonged and profound neutropenia. Treatment consists of broad-spectrum antibiotic therapy and, when possible, incision and drainage.

  • Ecthyma gangrenosum is frequently seen in patients with acute leukemia and neutropenia. Gram-negative rods, mainly Pseudomonas aeruginosa, are the most common etiology. Diagnosis is based on clinical suspicion and biopsy of the lesion. Treatment involves empiric antibiotic therapy until final identification of the causative organism. Surgical excision is often necessary.

  • Necrotic tumors involving the skin are at risk of secondary polymicrobial infection. Treatment is difficult as antimicrobials may not adequately reach the site of infection due to the impairment in blood supply.

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References

  1. Aronoff DM, Bloch KC. Assessing the relationship between the use of nonsteroidal antiinflammatory drugs and necrotizing fasciitis caused by group A streptococcus. Medicine (Baltimore). 2003;82:225–35.

    CAS  Google Scholar 

  2. Barnes SG, Sattler FR, Ballard JO. Perirectal infections in acute leukemia. Improved survival after incision and debridement. Ann Intern Med. 1984;100:515–8.

    Article  CAS  Google Scholar 

  3. Bechar J, Sepehripour S, Hardwicke J, Filobbos G. Laboratory risk indicator for necrotising fasciitis (LRINEC) score for the assessment of early necrotising fasciitis: a systematic review of the literature. Ann R Coll Surg Engl. 2017;99:341–6.

    Article  CAS  Google Scholar 

  4. Bilton BD, Zibari GB, McMillan RW, Aultman DF, Dunn G, McDonald JC. Aggressive surgical management of necrotizing fasciitis serves to decrease mortality: a retrospective study. Am Surg. 1998;64:397–400; discussion 400-1.

    CAS  PubMed  Google Scholar 

  5. Bocking N, Matsumoto CL, Loewen K, Teatero S, MArchand-Austin A, Gordon J, Fittipaldi N, McGeer A. High incidence of invasive group A streptococcal infections in remote indigenous communities in northwestern Ontario, Canada. Open Forum Infect Dis. 2017;4:ofw243.

    PubMed  Google Scholar 

  6. Bodey GP, Rodriguez S, Fainstein V, Elting LS. Clostridial bacteremia in cancer patients. A 12-year experience. Cancer. 1991;67:1928–42.

    Article  CAS  Google Scholar 

  7. Burner E, Henderson SO, Burke G, Nakashioya J, Hoffman JR. Inadequate sensitivity of laboratory risk indicator to rule out necrotizing fasciitis in the emergency department. West J Emerg Med. 2016;17:333–6.

    Article  Google Scholar 

  8. Carbonetti F, Cremona A, Carusi V, Guidi M, Iannicelli E, Di Girolamo M, Sergi D, Clarioni A, Baio G, Antonelli G, Fratini L, David V. The role of contrast enhanced computed tomography in the diagnosis of necrotizing fasciitis and comparison with the laboratory risk indicator for necrotizing fasciitis (LRINEC). Radiol Med. 2016;121:106–21.

    Article  Google Scholar 

  9. Crisp JG, Takhar SS, Moran GJ, Krishnadasan A, Dowd SE, Finegold SM, Summanen PH, Talan DA, EMERGEncy ID Net Study Group. Inability of polymerase chain reaction, pyrosequencing, and culture of infected and uninfected site skin biopsy specimens to identify the cause of cellulitis. Clin Infect Dis. 2015;61:1679–87.

    CAS  PubMed  Google Scholar 

  10. Darenberg J, Ihendyane N, Sjolin J, Aufwerber E, Haidl S, Follin P, Andersson J, Norrby-Teglund A, Streptig Study Group. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial. Clin Infect Dis. 2003;37:333–40.

    Article  CAS  Google Scholar 

  11. Elting LS, Rubenstein EB, Rolston KV, Bodey GP. Outcomes of bacteremia in patients with cancer and neutropenia: observations from two decades of epidemiological and clinical trials. Clin Infect Dis. 1997;25:247–59.

    Article  CAS  Google Scholar 

  12. Eriksson B, Jorup-ronstrom C, Karkkonen K, Sjoblom AC, Holm SE. Erysipelas: clinical and bacteriologic spectrum and serological aspects. Clin Infect Dis. 1996;23:1091–8.

    Article  CAS  Google Scholar 

  13. Flanagan CE, Daramola OO, Maisel RH, Adkinson C, Odland RM. Surgical debridement and adjunctive hyperbaric oxygen in cervical necrotizing fasciitis. Otolaryngol Head Neck Surg. 2009;140:730–4.

    Article  Google Scholar 

  14. Glass GE, Sheil F, Ruston JC, Butler PE. Necrotising soft tissue infection in a UK metropolitan population. Ann R Coll Surg Engl. 2015;97:46–51.

    Article  CAS  Google Scholar 

  15. Hamilton SM, Bayer CR, Stevens DL, Lieber RL, Bryant AE. Muscle injury, vimentin expression, and nonsteroidal anti-inflammatory drugs predispose to cryptic group A streptococcal necrotizing infection. J Infect Dis. 2008;198:1692–8.

    Article  CAS  Google Scholar 

  16. Holland MJ. Application of the Laboratory Risk Indicator in Necrotising Fasciitis (LRINEC) score to patients in a tropical tertiary referral centre. Anaesth Intensive Care. 2009;37:588–92.

    Article  CAS  Google Scholar 

  17. Jallali N, Withey S, Butler PE. Hyperbaric oxygen as adjuvant therapy in the management of necrotizing fasciitis. Am J Surg. 2005;189:462–6.

    Article  CAS  Google Scholar 

  18. Kadri SS, Swihart BJ, Bonne SL, Hohmann SF, Hennessy LV, Louras P, Evans HL, Rhee C, Suffredini AF, Hooper DC, Follmann DA, Bulger EM, Danner RL. Impact of intravenous immunoglobulin on survival in necrotizing fasciitis with vasopressor-dependent shock: a propensity score-matched analysis from 130 US hospitals. Clin Infect Dis. 2017;64:877–85.

    PubMed  Google Scholar 

  19. Kato T, Fujimoto N, Honda S, Fujii N, Shirai M, Nakanishi T, Nakanishi G, Tanaka T. Usefulness of serum procalcitonin for early discrimination between necrotizing fasciitis and cellulitis. Acta Derm Venereol. 2017;97:141–2.

    Article  Google Scholar 

  20. Linner A, Darenberg J, Sjolin J, Henriques-Normark B, Norrby-Teglund A. Clinical efficacy of polyspecific intravenous immunoglobulin therapy in patients with streptococcal toxic shock syndrome: a comparative observational study. Clin Infect Dis. 2014;59:851–7.

    Article  CAS  Google Scholar 

  21. Majeski J, Majeski E. Necrotizing fasciitis: improved survival with early recognition by tissue biopsy and aggressive surgical treatment. South Med J. 1997;90:1065–8.

    Article  CAS  Google Scholar 

  22. McHenry CR, Piotrowski JJ, Petrinic D, Malangoni MA. Determinants of mortality for necrotizing soft-tissue infections. Ann Surg. 1995;221:558–63; discussion 563-5.

    Article  CAS  Google Scholar 

  23. Mikaeloff Y, Kezouh A, Suissa S. Nonsteroidal anti-inflammatory drug use and the risk of severe skin and soft tissue complications in patients with varicella or zoster disease. Br J Clin Pharmacol. 2008;65:203–9.

    Article  Google Scholar 

  24. Misiakos EP, Bagias G, Papadopoulos I, Danias N, Patapis P, Machairas N, Karatzas T, Arkadopoulos N, Toutouzas K, Alexakis N, Konstantoulakis MN, Zografos G, Smyrniotis V, Kouraklis G, Machairas A. Early diagnosis and surgical treatment for necrotizing fasciitis: a multicenter Study. Front Surg. 2017;4:5.

    PubMed  PubMed Central  Google Scholar 

  25. O’Sullivan GM, Worsnop F, Natkunarajah J. Ecthyma gangrenosum, an important cutaneous infection to recognize in the immunosuppressed patient. Clin Exp Dermatol. 2018;43:67–9.

    Article  Google Scholar 

  26. Perl B, Gottehrer NP, Raveh D, Schlesinger Y, Rudensky B, Yinnon AM. Cost-effectiveness of blood cultures for adult patients with cellulitis. Clin Infect Dis. 1999;29:1483–8.

    Article  CAS  Google Scholar 

  27. Quirke M, Ayoub F, McCabe A, Boland F, Smith B, O'Sullivan R, Wakai A. Risk factors for nonpurulent leg cellulitis: a systematic review and meta-analysis. Br J Dermatol. 2017;177:382–94.

    Article  CAS  Google Scholar 

  28. Rolston KV, Bodey GP. Diagnosis and management of perianal and perirectal infection in the granulocytopenic patient. Curr Clin Top Infect Dis. 1993;13:164–71.

    CAS  PubMed  Google Scholar 

  29. Singer AJ, Talan DA. Management of skin abscesses in the era of methicillin-resistant Staphylococcus aureus. N Engl J Med. 2014;370:1039–47.

    Article  CAS  Google Scholar 

  30. Stevens DL, Bryant AE. Necrotizing soft-tissue infections. N Engl J Med. 2018;378:971.

    Article  Google Scholar 

  31. Stevens DL, Musher DM, Watson DA, Eddy H, Hamill RJ, Gyorkey F, Rosen H, Mader J. Spontaneous, nontraumatic gangrene due to Clostridium septicum. Rev Infect Dis. 1990;12:286–96.

    Article  CAS  Google Scholar 

  32. Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJ, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC, Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59:e10–52.

    Article  Google Scholar 

  33. Swartz MN. Clinical practice. Cellulitis. N Engl J Med. 2004;350:904–12.

    Article  CAS  Google Scholar 

  34. Vaiman M, Lazarovitch T, Heller L, Lotan G. Ecthyma gangrenosum and ecthyma-like lesions: review article. Eur J Clin Microbiol Infect Dis. 2015;34:633–9.

    Article  CAS  Google Scholar 

  35. Willy C, Rieger H, Vogt D. Hyperbaric oxygen therapy for necrotizing soft tissue infections: contra. Chirurg. 2012;83:960–72.

    Article  CAS  Google Scholar 

  36. Wong CH, Chang HC, Pasupathy S, Khin LW, Tan JL, Low CO. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am. 2003;85-A:1454–60.

    Article  Google Scholar 

  37. Wong CH, Khin LW, Heng KS, Tan KC, Low CO. The LRINEC (Laboratory Risk Indicator for Necrotizing fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft tissue infections. Crit Care Med. 2004;32:1535–41.

    Article  Google Scholar 

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Authors and Affiliations

  1. Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Ariel D. Szvalb & Kenneth V. I. Rolston

Authors
  1. Ariel D. Szvalb
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  2. Kenneth V. I. Rolston
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Correspondence to Ariel D. Szvalb .

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Editors and Affiliations

  1. Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Joseph L. Nates

  2. Division of Anesthesiology, Critical Care and Pain Medicine, Department of Critical Care and Respiratory Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Kristen J. Price

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Szvalb, A.D., Rolston, K.V.I. (2020). Skin and Soft Tissue Infections Among Cancer Patients. In: Nates, J., Price, K. (eds) Oncologic Critical Care. Springer, Cham. https://doi.org/10.1007/978-3-319-74588-6_129

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  • DOI: https://doi.org/10.1007/978-3-319-74588-6_129

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-74587-9

  • Online ISBN: 978-3-319-74588-6

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