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Common Bacterial Infections in Children 93

usually occur in the neck. It is characterised by extensive necrosis, with partments become tense and oedematous. Presence of gas in the tis-
multiple abscesses that drain on the surface by multiple sinuses and sue is responsible for the crepitus seen in these patients. In lacerated,
ultimately unite to form a large area of tissue necrosis. Staphylococcus devascularised, and contaminated wounds, the chances of gas gangrene
aureus is the causative organism in most cases. Treatment consists of increase manifold. The incubation period varies from 1 day to several
drainage of abscesses and excision of the dead and necrotic tissue. weeks, but is usually less than 3 days.
Intravenous broad-spectrum antibiotics help in the control of infection. Initially, the wound may not look very bad and there is no smell,
Extensive tissue destruction may require skin grafting in few cases. but once the process of myonecrosis has initiated, it rapidly progresses
Cellulitis to involve the adjacent tissue and foul smell is evident. The affected
Cellulitis is a spreading infection in the subcutaneous tissue planes. It area becomes tense, oedematous and severely tender. If not treated
may occur after a small skin breach, especially in immunocompromised adequately, the patient may soon develop generalised sepsis and renal
children. Insect bites, local trauma, vascular insufficiency, and diabe- shutdown. Death is possible due to multiple organ failure.
tes are some of the predisposing factors in the causation of celluitis. Diagnosis and Treatment
Cellulitis may also occur secondary to other soft tissue infections such Diagnosis is usually obvious by the nature of the trauma and deterioration
as furuncles or carbuncles. Classic signs of inflammation include red- of the patient’s condition a few days after the injury. X-ray will show gas
ness, pain, swelling, warmth, and loss of function. The skin overlying in the tissue with foreign bodies. The aim of management in extensive
the affected area is shiny and red. The patient may develop fever with injury shall be to prevent gas gangrene and aggressive therapy for those
chills, malaise, and body aches. It is important to identify the underly- who have developed the disease. Prevention and management may be
ing primary pathology, such as diabetes. Staphylococci, streptococci, achieved by adequate resuscitation of the patient after injury, thorough
and even gram-negative organisms may be responsible for the lesion. debridement of dead and dying tissue, removal of all foreign bodies from
The goals of treatment are control of infection and prevention of com- the wound, thorough washing of the wound, keeping the haemoglobin
plications. Treatment includes correction of contributing factors, broad- to an optimal level for good tissue oxygenation, use of broad-spectrum
spectrum antibiotics, and analgesics. Hospitalisation may be required antibiotics, and prophylactic use of hyperbaric oxygen where facilities
in extensive involvement. Facial cellulitis, also called erysipelas, is a are available. The broad-spectrum antibiotics include cover for gram-
serious condition and needs hospitalisation and intravenous antibiot- positive, gram-negative, and anaerobic organisms. Intravenous benzyl
ics. Spreading cellulitis in the floor of the mouth may cause Ludwig’s penicillin is the drug of choice and should be given to all suspected cases
angina, which may threaten the life of the patients due to laryngeal of gas gangrene every 4 to 6 hours. Anti-gas gangrene globulin may also
oedema and airway obstruction. Steroids may be required along with be useful if used early in the course of the illness.
antibiotics, and in some cases a tracheotomy may be required to relieve The main focus of management should be to surgically remove all
airway obstruction. dead and dying tissue. The procedure shall be performed under general
Pyomyositis Tropical anaesthesia and may be repeated after 24 hours to ensure drainage of all
infected areas, excision of dead tissue, and amputations if necessary. All
Pyomyositis tropical is a fulminant infection of the muscles. It is caused
wounds must be left open with loose dressing to ensure good circulation
by Staphylococcus aureus, but other organisms such as streptococcus
and to avoid ischaemia due to compartment syndrome. Where hyperbaric
and gram-negative organisms may be responsible. Multiple abscesses
oxygen therapy is possible, it should be given for 1–2 hours at 2.5
may be formed in different parts of the body. The child presents with
atmospheric pressure.
high-grade fever and chills with abscess formation. Abscesses are
formed in various muscles of the body. The infective process may Necrotising Fasciitis
affect other tissues of the body; meningitis, pericardial effusions, Necrotising fasciitis (NF) is a fulminant soft tissue infection causing
and endocarditis may be present. Empyema thorax is another serious extensive fascial, fat, and muscle necrosis. Due to extensive tissue
complication of pyomyositis tropical. The disease is commonly seen in destruction, it has been described as the “flesh-eating disease”. The con-
immuncompromised patients, especially those with human immunode- dition is not common and is mostly seen in malnourished, immunocom-
ficiency virus (HIV) and those on chemotherapy. Blood cultures will promised, and debilitated patients. Two types are described: Type-I NF
grow the organism and also help in deciding appropriate antibiotics. is a polymicrobial synergistic infection caused by anaerobes (bacteroi-
Antibiotics of choice for pyomyositis tropical are cloxacillin, fuscidic des and peptostreptococci), facultative anaerobes (non–beta-haemolytic
acid, and cephalosporin. Fuscidic acid preparations are expensive and streptococci) and Enterobacter species (Escherichia coli, Enterobacter,
not easily available, but are very effective due to good tissue and bone Klebsiella, and Proteus). Type-II NF is caused by group A beta-haemolyt-
penetration. A combination of cloxacillin and gentamicin may help to ic streptococcal (GABHS) infection, and is often described as streptococ-
restrain the infection. Draining of abscesses should be performed early cal myonecrosis. The true incidence of NF is not known; however, the
and may help prevent extension of the disease to other organs and tis- disease is commonly seen in children in the developing countries.
sues. See Chapter 19 for additional information.
Type-I Necrotising Fasciitis
Various forms of type-I NF include Meleney’s progressive bacte-
Clostridia Myonecrosis (Gas Gangrene) rial gangrene, Fournier’s gangrene, cancrum oris, and noma vulva. In
Gas gangrene is a fulminant synergistic infection caused by mixed children, severe systemic diseases, such as gastroenteritis, sepsis, gut
infections by saccharolytic and proteolytic organisms. The organisms perforations, and omphalitis, may predispose the patient to infective
involved are Clostridium perfirngens, Clostridium oedemateins, and gangrene. Type-I NF involves the abdominal wall, perineum, groin,
Clostridium septicum. Clostridia are facultative anaerobes and grow and postoperative wounds. Rarely, it may affect the oral cavity. In
rapidly in low oxygen. Gas gangrene is commonly seen in war situa- newborn babies, umbilical infection secondary to poor hygiene can
tions; however, in civilian practice it may also be seen after roadside cause rapidly spreading gangrene of the umbilicus. Initially, erythema
accidents and in dirty and contaminated wounds. Its true incidence is and hyperaemia develop in the affected area and rapidly spread to local
not known, but it may occur in 0.1 per 100,000 per annum. tissue necrosis and may spread to the abdominal and chest walls. Most
Indications babies have polymicrobial infections. Multiple organisms are usually
The clostridia strains produce various exotoxins and cause extensive recovered from the patients, and the number of isolates varies from two
necrosis of tissue proteins, fats, and red blood cells. The tissue com- to six, averaging 3.5 isolates per specimen. Patients need aggressive
supportive therapy along with a combination of antibiotics from gram-