Adult ; Buprenorphine ; adverse effects ; Disease Progression ; Humans ; Male ; Narcotics ; adverse effects ; Soft Tissue Infections ; chemically induced ; diagnosis ; etiology ; Substance Abuse, Intravenous ; complications ; Substance-Related Disorders ; complications ; diagnosis ; Vascular Diseases ; chemically induced ; diagnosis ; etiology

INTRODUCTIONHand infections in patients with end-stage renal failure (ESRF) are more diffi cult to treat and have had the worse outcomes. This paper examines the epidemiology, bacteriology and outcomes of surgically managed upper limb infections in these vulnerable patients.

MATERIALS AND METHODSAll patients from a single centre with surgically-managed upper limb infections between 2001 and 2007 were reviewed. We collected epidemiological data on demographics, type and site of infection, bacteriology, surgical treatment, complications and mortality.

RESULTSForty-seven out of 803 (6%) patients with surgically managed upper limb infections in the study period had ESRF. The average age was 59 years. ESRF was secondary to diabetes in 88% of cases. Patients presented on average 7 days after onset of symptoms. Abscesses (34%), wet gangrene (26%) and osteomyelitis (11%) were the commonest infections. Methicillin-resistant Staphylococcus aureus (MRSA) was the commonest pathogen (29%), occurring either in isolation or with other organisms. Eighteen percent of single organisms cultured were gram-negative. Multiple organisms occurred in 29%. A median of 2 operations were required. Thirty-six percent of all cases required amputation. Twenty-fi ve percent of patients had a life-threatening event (myocardial infarction or septic shock) during treatment.

CONCLUSIONSESRF patients present late with severe upper limb infections. Nosocomial infections are common. Initial empirical antibiotic treatment should cover MRSA and gram-negative bacteria. Immediate referral to a hand surgery unit is recommended. Multi-disciplinary management of the patient with input from physicians and anaesthetists or intensivists in the perioperative period is necessary to optimise the patient for surgery and to manage active medical comorbidities and complications after surgery.

Adult ; Aged ; Aged, 80 and over ; Amputation ; Diabetes Complications ; Epidemiologic Studies ; Female ; Hand ; surgery ; Hand Injuries ; epidemiology ; etiology ; surgery ; Humans ; Kidney Failure, Chronic ; complications ; epidemiology ; Male ; Methicillin-Resistant Staphylococcus aureus ; Middle Aged ; Retrospective Studies ; Risk Factors ; Singapore ; epidemiology ; Surgical Wound Infection ; drug therapy ; epidemiology ; etiology

INTRODUCTIONNecrotising fasciitis is a disease associated with high morbidity and mortality, and multi-focal necrotising fasciitis is uncommon. We present 2 cases of concurrent necrotising fasciitis of contralateral upper and lower limbs.

CLINICAL PICTUREBoth presented with pain, swelling, bruising or necrosis of the affected extremities. Traditional medical therapy was sought prior to their presentation.

TREATMENTAfter initial debridement, one patient subsequently underwent amputation of the contralateral forearm and leg. The other underwent a forearm amputation, but refused a below-knee amputation.

OUTCOMEThe first patient survived, while the second died.

CONCLUSIONTraditional medical therapy can cause bacterial inoculation, leading to necrotising fasciitis, and also leads to delay in appropriate treatment. Radical surgery is needed to optimise patient survival.

Aged ; Amputation ; Debridement ; Fasciitis, Necrotizing ; diagnosis ; drug therapy ; surgery ; Fatal Outcome ; Female ; Hand ; microbiology ; surgery ; Humans ; Leg ; microbiology ; surgery ; Male ; Medicine, East Asian Traditional ; Middle Aged ; Risk Factors