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Treating Severe Soft Tissue Infections: How and What I Do

  • Authors: Chair: Pamela A. Lipsett, MD, FACS, FCCM
    Faculty: Gregory J. Beilman, MD, FACS; Eileen M. Bulger, MD, FACS; Robert G. Sawyer, MD, FACS
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Target Audience and Goal Statement

Surgeons, physicians, scientists, medicinal pharmacologists and drug industry developers who are interested in the epidemiology, risk factors, treatment and outcome of surgical infections due to gram-positive pathogens.

Gram positive pathogens are increasingly identified as causing serious infections in surgical patients. Over the last few years, the bacteriology, presentation, virulence and treatment have evolved. Methicillin-resistant S aureus (MRSA) has become widespread in hospitals and intensive care units around the world. MRSA is now one of the most common causes of bacterial nosocomial infections, accounting for 40-70% of the S aureus infections in intensive care units. In the past, acquisition of MRSA colonization or infection was generally considered to be restricted to the nosocomial setting. However, in the past decade new strains of MRSA have emerged in the community, causing aggressive infections in young, otherwise healthy people. Identifying this changing cause of soft tissue infection and the need for new consensus and guidelines are obvious. Suppurative skin infections and severe necrotizing pneumonias are the most well-known clinical syndromes caused by these new strains. The increasing prevalence of community-acquired MRSA in multiple countries and the substantial morbidity and mortality associated with these infections suggest that community-acquired MRSA will continue to develop into a challenging public-health problem which all physicians should become aware. In recent years, serious skin and soft tissue infections (SSTIs) caused by multidrug resistant pathogens have become more common. While the majority of SSTIs are caused by Staphylococcu S aureus or beta-haemolytic streptococci that are methicillin/oxacillin susceptible, the emergence of methicillin-resistant and vancomycin-resistant community-acquired and nosocomial Gram-positive pathogens has created a need for different therapeutic agents. While antibiotics are important, the identification of patients who need immediate surgical treatment is paramount.

While pneumonia and soft-tissue infections seem to be increasing due to community acquired MRSA, bacteremia and endocarditis continue to have significant morbidity and mortality. Recent publications have documented the importance of both prevention and treatment of this morbid disease.

Upon completion of this activity, participants should be able to:

  1. Identify the increasing importance of both gram-positive pathogens and especially community acquired MRSA in surgical infections.
  2. Describe state of the art management of complicated soft-tissue infection.
  3. Characterize the diagnostic modalities and treatment options for endocarditis in surgical patients in 2005 and beyond.


As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation.  The presenting faculty reported the following.


  • Gregory J. Beilman, MD, FACS

    Associate Professor, Department of Surgery, University of Minnesota, Minneapolis, MN


    Disclosure: Dr. Beilman has no significant financial interests or relationships to disclose.

  • Pamela A. Lipsett, MD, FACS, FCCM

    Hopkins Faculty Program Director/Chair; Professor of Surgery, Anesthesiology, and Critical Care Medicine; and Nursing, Co-Director of the Surgical Intensive Care Units, Johns Hopkins University Schools of Medicine and Nursing


    Disclosure: Dr. Lipsett has no significant financial interests or relationships to disclose.

  • Robert G. Sawyer, MD, FACS

    Associate Professor, University of Virginia Health Systems, Charlottesville, VA


    Disclosure: Grants/Research Support: Pfizer, Wyeth, Cubist; Consultant: Wyeth, Merck, Pfizer; Honorarium: Wyeth, Cubist, Merck, Pfizer

  • Eileen M. Bulger, MD, FACS

    Associate Professor, Assistant Residency Program Director, Harborview Medical Center, Department of Surgery, Seattle, WA


    Disclosure: Dr. Bulger has no significant financial interests or relationships to disclose.

The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combination of drugs, including indications, contraindications, warnings and adverse effects before administering pharmacologic therapy to patients.

No faculty member has indicated that their presentation will include information on off-label products.

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  • The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

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    The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2.5 AMA PRA Category 1 Credits. Physicians should only claim credit commensurate with the extent of their participation in the activity.

    Estimated time to complete activity 2.5 hours.

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Treating Severe Soft Tissue Infections: How and What I Do: Plasmapheresis



  • Plasmapheresis is different from hemofiltration because it involves an actual plasma exchange. Its potential benefits include the removal of toxin, which is what we think causes the immediate circulatory collapse of many of these patients; potential removal of inflammatory cytokines, we don't really know if that is true or not; and replacement of plasma factors, which may be important for patients with coagulopathy.

  • Plasmapheresis

    Slide 32.


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  • There have been some case reports in a small series suggesting anecdotal benefit in septic shock. There is only 1 randomized controlled trial in the literature, and it's a paper from Intensive Care Medicine. It is small; 106 patients with septic shock were randomized to either receive plasmapheresis or not. Mortality was 33% in the plasmapheresis group, 54% in the controls, which was significant on univariate analysis but did not reach significance on multivariate analysis. This again was a generalized population of sepsis, not necessarily necrotizing soft tissue infections. There were only 2 case reports in the literature specific to necrotizing soft tissue infection, 1 of which is from our own institution. So, we do use this, but we haven't really had very good data.

  • Plasmapheresis

    Slide 33.


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