post surgical necrotizing soft tissue infection can have shock and dishwasher fluid appearance

This patient has a necrotizing soft-tissue infection, which is a surgical emergency (choice A is correct). Necrotizing infections are rare but potentially fatal complications after surgery and must be rapidly recognized. Typical characteristics of necrotizing infections include rapid onset of symptoms with progression to systemic infection and shock, disproportionate pain in the affected area, and variable skin changes (erythema, discoloration, or blistering). The presence of grayish fluid (so-called dishwater fluid) is suggestive of necrotizing fasciitis. Crepitus may be felt when gas-producing organisms are present; this occurs in less than 30% of cases.

Performing imaging studies should not delay surgical debridement (choice B is incorrect). Early and aggressive antibiotic therapy should be started in conjunction with surgical management. Initial empiric antibiotics should provide broad-spectrum coverage of polymicrobial infections, including methicillin-resistant Staphylococcus aureus, Gram-negative rods, and anaerobic bacteria; immediate antifungal coverage is not required (choice C is incorrect). Necrotizing soft-tissue infections are more likely to develop in patients with underlying chronic medical conditions, including diabetes mellitus and obesity, but acute control of hyperglycemia is not the most important issue to address immediately in this patient (choice D is incorrect).

Approximately 50% of patients with necrotizing fasciitis develop toxic shock syndrome (TSS), a complication of invasive Group A Streptococcus infection. Clinical criteria for streptococcal TSS include hypotension and multiorgan involvement characterized by two or more of the following: renal impairment, coagulopathy, liver involvement, ARDS, erythematous macular rash, and soft-tissue necrosis. Blood cultures are positive for Group A Streptococcus in approximately 60% of cases. Management of TSS requires coordinated care among critical care providers, surgeons, and infectious disease specialists. Antibiotic therapy generally consists of a beta-lactam agent (which inhibits cell wall synthesis) in combination with clindamycin (which inhibits protein synthesis).1

Footnotes

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