What is the appropriate workup and management for a patient with fungating breast cancer, not on chemotherapy, presenting with a protrusion through the skin that is infected, causing left breast cellulitis and subsequent sepsis?

From the Guidelines

For a patient with fungating breast cancer complicated by infection, cellulitis, and sepsis, immediate hospitalization is necessary to manage the severe infection and prevent further complications. The patient's condition is critical, and prompt treatment is required to address the sepsis and cellulitis. Initial management includes blood cultures, complete blood count, comprehensive metabolic panel, and wound cultures, as recommended by the Infectious Diseases Society of America 1.

Key Considerations

• Empiric broad-spectrum IV antibiotics should be started immediately, typically with vancomycin 15-20 mg/kg IV q12h plus piperacillin-tazobactam 4.5g IV q6h or meropenem 1g IV q8h to cover both gram-positive and gram-negative organisms, including MRSA and anaerobes commonly found in these infections 1.
• Fluid resuscitation and hemodynamic support are crucial for managing sepsis.
• The wound requires gentle cleansing with saline and application of appropriate dressings such as metronidazole gel or silver-containing dressings to control odor and exudate.
• Elevation of the affected area and treatment of predisposing factors, such as edema or underlying cutaneous disorders, are recommended 1.

Additional Management

• Once the acute infection is controlled, oncology consultation is essential to discuss treatment options including surgical debridement, radiation therapy, or palliative chemotherapy.
• Pain management with appropriate analgesics is important throughout treatment.
• The recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period 1.
• Outpatient therapy is not recommended for patients with SIRS, altered mental status, or hemodynamic instability, and hospitalization is necessary to ensure close monitoring and management 1.

From the FDA Drug Label

1.3 Skin and Skin Structure Infections

Piperacillin and tazobactam for injection, USP is indicated in adults for the treatment of uncomplicated and complicated skin and skin structure infections, including cellulitis, cutaneous abscesses and ischemic/diabetic foot infections caused by beta-lactamase producing isolates of Staphylococcus aureus.

The appropriate management for a patient with fungating breast cancer, not on chemotherapy, presenting with a protrusion through the skin that is infected, causing left breast cellulitis and subsequent sepsis, may include the use of Piperacillin/Tazobactam (IV) for the treatment of cellulitis, as it is indicated for complicated skin and skin structure infections, including cellulitis.

• The patient should be treated with broad-spectrum antibiotics, such as Piperacillin/Tazobactam, to cover potential bacterial pathogens.
• Sepsis management should also be initiated, following standard protocols for sepsis treatment.
• Wound care and infection control measures should be implemented to prevent further infection and promote healing. 2

From the Research

Appropriate Workup and Management

The patient with fungating breast cancer presenting with a protrusion through the skin that is infected, causing left breast cellulitis and subsequent sepsis, requires a comprehensive management approach.

• The management of fungating breast cancer involves a multidisciplinary approach, including medical management of the locally advanced breast cancer, addressing psychosocial complications, pain management, and wound care with appropriate dressing recommendations according to the specific wound characteristics 3.
• Surgical management may be considered, with mastectomy being a common procedure, and reconstructive techniques may be used for wound closure 4, 5.
• Intra-arterial chemotherapy may be an option for palliation in carefully selected cases 6.
• Topical agents and dressings, such as 6% miltefosine solution and foam dressings containing silver, may be effective in slowing disease progression and reducing malodour 7.

Considerations for Infection and Sepsis

• The presence of infection and sepsis requires prompt antibiotic treatment and supportive care to manage the patient's condition.
• The management of fungating wounds aims to slow disease progression and optimize quality of life by alleviating physical symptoms, such as copious exudate, malodour, pain, and the risk of haemorrhage 7.
• A patient-centered approach is essential in managing the patient with fungating breast cancer, taking into account their individual needs and preferences 3.

Reconstructive Techniques

• Reconstructive techniques, such as split-thickness skin grafting and thoracoepigastric advancement, latissimus dorsi, trapezius, and extended transverse and vertical rectus abdominis flaps, may be used for wound closure 5.
• The choice of reconstructive technique depends on the individual patient's needs and the extent of the wound.
• Reconstructive techniques can be effective in palliating pain and reducing wound care needs, with low complication rates 5.