E. J. C. G. has served as a consultant to Schering-Plough, ViraPharm, Replidyne, Occulus Innovative Sciences, Theravance, Cerexa, Merck, and Optimer Pharmaceuticals; has received honoraria from Merck, Johnson & Johnson; and has received research grants from Replidyne, Occulus Innovative Sciences, Cubist, Theravance, Pfizer, Cerexa, Johnson & Johnson, Merck, and Optimer Pharmaceuticals. However, features that suggest involvement of deeper tissues include (1) severe pain that seems disproportional to the clinical findings; (2) failure to respond to initial antibiotic therapy; (3) the hard, wooden feel of the subcutaneous tissue, extending beyond the area of apparent skin involvement; (4) systemic toxicity, often with altered mental status; (5) edema or tenderness extending beyond the cutaneous erythema; (6) crepitus, indicating gas in the tissues; (7) bullous lesions; and (8) skin necrosis or ecchymoses.Computed tomography (CT) or magnetic resonance imaging (MRI) may show edema extending along the fascial plane, although the sensitivity and specificity of these imaging studies are ill defined. One observational study demonstrated better outcomes in patients receiving IVIG, but this report was confounded because IVIG recipients were more likely to have had surgery and to have received clindamycin than the historical controls [119]. Treatment of severe cases should be extended to 14 days.For mild to moderate disease, oral tetracycline (500 mg qid) or doxycycline (100 mg bid) is appropriate. Prospective studies evaluating the yield of skin biopsy or aspiration have not been performed in adult immunocompromised patients, but most clinicians who manage these patients combine blood cultures, serial antigen detection, nucleic acid amplification techniques, radiographic imaging, and a biopsy or aspiration of the abnormal skin or soft tissue lesion in the hope of increasing the recovery of the offending pathogen and directing pathogen-specific antimicrobial therapy.This can occur during “initial” episode fever and neutropenia (first episode of neutropenic fever that requires systemic antimicrobial therapy) or during a “persisting episode” (persistent neutropenic fever unresponsive to broad-spectrum antimicrobial therapy beyond days 4–7) or during recurrent episodes of fever and neutropenia. Recipients of allogeneic blood and bone marrow transplants routinely take acyclovir (800 mg bid) or valacyclovir (500 mg bid) during the first year following transplant for the prevention of VZV and HSV reactivation [240]. One uncontrolled study reported termination of an epidemic of furunculosis in a village by use of mupirocin, antibacterial hand cleanser, and daily washing of towels, sheets, combs, and razors [33]. In such infections, immediate surgical exploration by a team experienced in the management of these patients and broad-spectrum antibiotic therapy targeted at gram-negative, gram-positive, and anaerobic bacteria are essential.Gram-positive pathogens are now the most common bacterial organisms isolated from diagnostic cultures obtained from febrile neutropenic patients [197, 198]. In suspected cases a small, exploratory incision made in the area of maximum suspicion can be useful for excluding or confirming the diagnosis. The average age at onset is 50–60 years. Radiographic imaging should be performed as clinically indicated, but can be helpful to define the extent of SSTIs when patients are neutropenic. Between 65% and 70% of adult patients are seropositive for VZV, and this identifies those patients at risk for future reactivation infection. Elevation of the affected area hastens improvement by promoting gravity drainage of edema and inflammatory substances. However, coverage for MRSA may be prudent in cellulitis associated with penetrating trauma, especially from illicit drug use, purulent drainage, or with concurrent evidence of MRSA infection elsewhere. The frequency of SSI is clearly related to the category of operation, with clean and low-risk operations (by NNIS classification) having the lowest incidence, and contaminated and high-risk operations having higher infection rates [79]. The need for rabies prophylaxis and/or therapy should be addressed.Purulent bite wounds and abscess are more likely to be polymicrobial (mixed aerobes and anaerobes), whereas nonpurulent wounds commonly yield staphylococci and streptococci [156, 157]. More than 20% of patients with chemotherapy-induced neutropenia develop a clinically documented infection involving the skin and soft tissues, but many are due to hematogenous dissemination [179].Cancer patients with fever and neutropenia can be divided into low- and high-risk groups [187]. Clindamycin suppresses streptococcal toxin and cytokine production. In about 10% of cases, the nodes suppurate. Specific recommendations for therapy are given, each with a rating that indicates the strength of and evidence for recommendations according to the Infectious Diseases Society of America (IDSA)/US Public Health Service grading system for rating recommendations in clinical guidelines (Table 1) [2].
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