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Pharmacotherapy > Bacterial Skin and Skin Structure Infection > Flashcards

Bacterial Skin and Skin Structure Infection Flashcards

1
Q

Symptoms of skin infections

A

Sspreading infections of dermis
Warmth, erythema, pain, swelling
Rapid onset, unilateral

Rredisposing factors:
_ diabetes and PVD
_ previous cutaneous damage
_ surgical procedures- disruption of lymphatic drainage

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2
Q

What other diseases or conditions may be mistaken with BSSSI?

A

deep vein thrombosis (DVT)
D-dimer
doppler ultrasound
CT/MRI

statis dermatitis | venous insufficiency

lipodermatosclerosis

drug-induced edema

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3
Q

Differences purulence between BSSSI and other types

A

White, yellowish, cloudy

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4
Q

What are the indicators for causative pathogen for BSSSI (purulence)?

A

Stalph Aureus
GAS
Gram (+) stalph and strep

MRSA/MSSA
B-hemolytic/ non-B hemolytic

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5
Q

Cellulitis vs Abscess

A

Cellulitis/erysipelas (non-purulent)
Diffuse, superficial, spreading skin infections

Cutaneous/skin Abscess (purulent)
Collections of pus within the dermis and deeper skin tissues
Painful, tender, fluctuant red nodules

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6
Q

Panton-Valentine leukocidin (PVL) toxin

A

“PVL toxin genes were present in almost all MRSA strains”

S.aureus produced PVL toxin –> punch hole on WBC —> WBC leak its contents –> degradative enzyme leak –> degrade skin –> cellulitis

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7
Q

CA-MRSA vs HA-MRSA

A

table in ppt

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8
Q

What kind of bacteria is Strep Pyogenes ?

A

GAS and MSSA and aerobic

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9
Q

Oral ABx for active against Strep. Pyogene

A

Active against Strep. pyogenes (GAS) & MSSA
Dicloxacillin 500mg PO Q6hrs
_short half-life = frequent dosing
_poor GNR coverage

Cephalexin 500mg PO Q6hrs
_short half-life = frequent dosing
_RENAL adjustment (80-100% unchanged in urine)
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10
Q

Oral ABx for active against Strep. Pyogene with PCN allergy

A

PCN allergy: Clindamycin 300mg PO QID

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11
Q

IV ABx for active against Strep. Pyogene

A

Cefazolin (Ancef) 1gm IV Q8hrs
_ More convenient than nafcillin, less bone marrow suppression
_ Renal Adjust CrCl <30

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12
Q

IV ABx for active against Strep. Pyogene with PCN allergy

A

SEVERE PCN allergy: Clindamycin 600mg IV Q8hrs

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13
Q

NSAIDs (w/ risk) or systemic steroid accelerate improvement

A

IBU 400mg PO QID x5days,
OR
Prednisone 40mg PO daily x7days

Cardiovascular, bleeding risk, CKD

Complete cellulitis resolution with IBU at 4-5 days 100% versus >7days 30% of patients without IBU

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14
Q

What should always be done to abscess/purulence cases?

A

I&D alone >85% cure rate

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15
Q

How to classify purulence?

A

No systemic signs & small abscess <2cm (MILD)

SYSTEMIC signs &amp purulent, large abscess
I&D + SYSTEMIC ABxs (route based on severity) EMPIRIC MRSA
MODERATE: oral or IV then oral
SEVERE: IV then oral

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16
Q

MRSA coverage (oral)

A 
TMP-SMX 
Doxycycline 
Clindamycin 
Linezolid 
Tedizolid
17
Q

MRSA coverage (IV)

A 
Vancomycin
Daptomycin 
Linezolid 
TMP-SMX
Ceftaroline
Dalbavancin
Oritavancin
Tedizolid
18
Q

Length of therapy

A

5-day course

with 14 to 28 days for follow-up

19
Q

S/sx of severe skin infection

A 
severe local sxs
severe pain
rapidly spreading
fevers and chills
deep abscess

signs
hypotension
elevated SCr

20
Q

Alternatives to Vancomycin

A

daptomycin (Cubicin) 4mg/kg IV Q24h
MOA: Binds cell membranes; depolarization
CIDAL; Inhibits RNA/DNA/Protein Synthesis
pros: daily dosing, no need to monitor levels
cons: inactivated by lung surfactants
rhabdomyolysis – monitor CK Qweek
– avoid statins
linezolid (Zyvox) 600mg IV Q12hrs
pros: no dose adjustments; oral/IV
cons: thrombocytopenia, serotonin syndrome

21
Q

Clinical Impact Summary for BSSSI

A

Purulence to assess need for anti-MRSA

B-lactams for non-purulent cellulitis

NSAIDs to reduce inflammation

Shorter courses of therapy – 5days

22
Q

Necrotizing Fasciitis

A

Flesh eating
Major destruction of deep tissues, highly lethal

Early diagnosis and expedited tx necessary:
_ severe, disproportionate constant pain
_ gas in soft tissue
_ fever, leukocytosis, renal failure
_ rapid spread despite abx’s
_ wooden-hard feel of subcutaneous tissue
_ elevated CPK, CRP >150

23
Q

Pathogenesis of necrotizing fasciitis

A

S. pyogenes (Mostly, a very aggressive strain)

S. aureus

Facultative and anaerobic organisms:
_ surgical procedures of bowel or penetrating 
abdominal trauma
_ decubitus ulcer or perianal abscess
_ injection drug users
24
Q

General treatment for necrotizing fasciitis

A 
Immediate surgical consult
Surgical debridement- source control
repeated 24-36hrs after 1st debridement
                                 PLUS
ABx treatment: Combo for Empiric broad spectrum
25
Q

ABx treatment for necrotizing fasciitis

A 
Combo for Empiric broad spectrum
_ Vancomycin (MRSA and gram (+)): needs LD because it is a severe condition
_ Clindamycin (Anaerobic and toxin inhibition): 600mg TID IV
_ FQ (gram (-)): Cipro 400mg Q8h IV
26
Q

Hong long do we continue necrotizing fasciitis tx?

A

Continue until surgery no longer needed and no signs of systemic inflammation (10-14 days after the surgery)

27
Q

Prevention of Diabetic Foot Infection

A 
daily foot examination forcallus, blister, trauma
properly fitting shoes
look in shoes
no barefoot walking
clean, dry feet
properly manicured toenails
28
Q

Diabetic Foot Infection Microbiology

A 
Superficial infxns: 
aerobic GPC (S. aureus, S. agalactiae, S. pyogenes, CoNS)

Ulcerations/chronic infxns:
may include gram negative: enterobacteriaceace, Pseudomonas

Extensive wounds, necrosis, toxic:
may further include anaerobes (Bacteroides, Clostridium, Streptococci spp)

29
Q

ABx for diabetic foot infection

A

Received antibiotics in the past month?
Yes = include gram-negative bacilli coverage
No = target aerobic gram-positive cocci only

mild to moderate (OUTPATIENT) & no recent antibiotics, targeting aerobic GPC sufficient

First, Mild and NO Abx past month: use Keflex
Then, Mild and Abx past month: use Augmentin
If Mild and purulence (MRSA) use Bactrim, Clinda, Dox

most severe infections (HOSPITALIZED), broad-spectrum empiric antibiotic therapy, pending culture results
Amp-Sulbactam 3gm IV Q6h
+ Vancomycin wt based dosing (Severe need LD)

30
Q

Pseudomonas aeruginosa in diabetic foot infection

A

Often a nonpathogenic colonizer when isolated from wounds
P. aeruginosa is isolated in <10% of wounds

Risk factors:
patients who have been soaking their feet or prolonged water exposure.
(remember: Pseudomonas inhabits moist environments)
who have failed therapy with nonpseudomonal therapy

Recommended agents for empiric coverage are:
Piperacillin/Tazobactam: 4.5g Q6h
Ciprofloxacin

31
Q

Duration for diabetic foot infection

A

Mild-moderate (Oral): 1-3 weeks

Severe (Initial parenteral, switch to oral when possible): 2-4 weeks

Bone/Joint (Initial parenteral, switch to oral when possible): >3 months

32
Q

Why long duration in treating diabetic foot infection?

A

Diabetes –> Low vascularization to foot –> Low blood supply –> Low ABx concentration –> Needs longer time to reach optimal concentration

33
Q

Osteomylitis (Suspicious)

A

open, exposed fracture
ability to probe bone at base of ulcer
local swelling with bone pain on examination

34
Q

Osteomylitis (Heightened Suspicion)

A

elevated ESR and CRP: inflammation

infectious signs: WBC, temp, HR, RR

35
Q

Osteomylitis (Diagnostic)

A 
plain films (x-ray) may be falsely negative early
blurred margins
MRI/CT- may reveal destruction if x-ray normal
36
Q

Treatment for Osteomylitis

A

Intravenous Route and Long Duration
Empiric coverage in adults
vancomycin
+ Gram negative coverage if:
IVDU/surgical (pseudomonas risk)- cefepime; if allergy cipro
vertebrae- ceftriaxone; FQ if allergy
vascular insufficiency- refer to diabetic foot

37
Q

Osteomylitis tx duration

A

Acute therapy – parenteral therapy x 6-8 weeks

Best to prevent recurrence

38
Q

BSSSI monitoring

A

fever, HR, RR
WBCs
skin/clinical improvement/progression
serum creatinine- renally adjusted medication
cultures
specific drug tolerance, side effects, interactions

39
Q

Pt education

A

Keep draining wounds covered with clean, dry bandages
Maintain good personal hygiene with regular bathing and cleaning of hands with soap and water or an alcohol-based hand gel, particularly after touching infected skin or items that have directly contacted draining wound
Avoid reusing or sharing personal items that contact skin (razors, towels, linens)

Pharmacotherapy (27 decks)

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