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IPFC 5 > Cellulitis + Abcess patho > Flashcards

Cellulitis + Abcess patho Flashcards

1
Q

How can SSTI’s (skin and soft tissue infection) be classified based on? (3) Examples

A
  • Structure of skin involved (epidermis, dermis, subcutaneous fat and fascia)
  • Causative pathogen (yeast, lice, chickenpox, acne)
  • underlying pathology (surgery, diabetic feet with ulcers)
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2
Q

What are some of the skin barrier defenses (4)

A
  • Tight junctions between cells
  • Relative dryness to prevent bacterial growth
  • Mild acidity due sebum and sweat.
  • Constantly being shed to limit the amount of colonization
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3
Q

What are risk factors for uncomplicated cellulitis? (7)

A
  • Obese
  • Diabetes
  • Peripheral vascular disease
  • History of cellulitis

History of chronic venous stasis
Anything causing lymph obstruction: pregnancy, radiotherapy
Damage to physical skin: excessive dryness, cuts, burns, bites

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4
Q

In most cases of uncomplicated cellulitis and skin abscess, the bacteria introduced under the epidermis are present as ______

A

Skin colonizers

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5
Q

What are signs and symptoms of uncomplicatedd cellulitis

A
  • Redness that spread
  • swelling/edema “peau d’orange”,
  • fluid filled vesicles, warmth and pain
  • Also lymphangitis, leukocytosis and fever are possible
  • Symptoms are always UNILATERAL
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6
Q

Culture in cellulitis?

A

Skin cultures are useless in cellulitis since skin is colonized with all kinds of bacteria

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7
Q

What bacteria is often found in cellulitis

A

Group A strep (lancefield)

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8
Q

T/F Symptoms of cellulitis are dependent on amount of bacteria

A

False
- dependant on extent of inflammation

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9
Q

What are risk factors for Abscess (5)

A

Diabetes
IV use
contact with individuals with abscess
presences of S.aureus
Immunocompromised

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10
Q

What is Abscess?

A

Collection of pus in the dermis or subcutaneous tissue which develops following skin barrier damage or when bacteria travel along a hair follicle.

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11
Q

Which bacteria is the major cause Abscess? Why?

A

Staph aureus
- due to its virulence factors that induce purulence and abscess

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12
Q

What are symptoms of abscess

A

Swollen, red, warm to the touch, and often painful.
- It may feel soft and fluctuant, indicating pus accumulation
- May appear above skin level and topped off with a pustule
May be below skin level and only redness will be seen on the surface

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13
Q

What are red flags of cellulitis and abscess (8)

A
  • Rapid spread
  • Sloughing skin (shedding)
  • Disproportionate pain
  • Widespread ecchymoses
  • Anesthesia of involved
  • Significant systemic toxicity
  • Localization over or inability to move joint
  • Hard, wooden feel of tissue
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14
Q

Differentiate between stasis dermatitis and cellulitis
Distribution
Onset
Clinical symptoms
Systemic symptoms

A

Distribution
- Stasis: Bilateral, often in medial ankle
- Cell: UNIlateral, broad lower spectrum

Onset
- Stasis: chronic
- Cell: Few hours to few days

Clinical symptoms
- Stasis: Usually pruritic, eczematous, red-brown pigmentation
- Cell: Erythema, tender and warm, shiny

Systemic symptoms
- Stasis: none
- Cell: can occur

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15
Q

What are exclusions of uncomplicated cellulitis (8)

A
  • Abscess
  • Cirrhosis
  • Necrotizing
  • Facial cellulitis
  • Immunocompromise
  • Presence of microbiological modifiers
  • Surgical site infection, chronic wound/ ulcer
  • Deeper involvement (eg. fascia, muscle, etc.)
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16
Q

What are symptomatic management of uncomplicated cellulitis (6)

A
  • Keep the area CLEAN
  • If there is a break in the skin -> protect the area
  • Saline compress: COLD or WARM, up to patient (evidence for both)
  • Analgesics
  • Elevation
  • Compression (only if elevation is not an option)
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17
Q

What is the problem with giving NSAIDs in cellulitis

A

Speeds up healing of inflammation HOWEVER may also increase risk of GAS

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18
Q

What do trials say about using compression stockings in cellulitis

A

Showed reduction in:
- pain
- tenderness
- edema
- hospitalization

May temporarily worsen symptoms by adding pressure, needs to be sized properly to prevent ulcers

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19
Q

Is topical therapy effective for cellulitis?

A

ALWAYS NO - They won’t penetrate deep enough for cellulitis
Could also cause contact dermatitis -> worsen skin symptoms

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20
Q

When is it absolutely necessary to give IV (4)

A
  • NPO
  • Ongoing vomiting
  • Unreliable absorption (incl. sepsis-induced hypotension)
  • Maybe acute severe sepsis
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21
Q

What agents have excellent oral bioavailability and should almost always be given orally (9)

A

Clindamycin
Metronidazole
Doxycycline
TMP-SMX
Linezolid
FQs (not azith but still give orally)

Amoxicillin
Cephalexin
Cefadroxil

22
Q

What agents have terrible oral bioavailability and should always be given parentally

A

Carbapenems
Vancomycin
Aminoglycosides
Penicillin G

23
Q

When would we likely need IV formulation in moderate cellulitis (systemic signs, 38+ fever) (3)

A

Obesity
Severe edema (too large Vol of distribution)
Bacteremia (need enough drug in the bloodstream)

24
Q

What are the harms of giving IV antimicrobials in cellulitis (2) and in general (2)

A
  • In cellulitis, associated fluid can exacerbate edema
  • In cellulitis, use of IV often leads to unnecessarily broad therapy for convenience of dosing (eg. ceftriaxone)

More ADRs
Risk for bloodstream infections

25
Q

What are 2 things to look out for when giving oral treatment to an outpatient which might require IV (3)

A

Morbid obesity (BMI 40+)
Very high edema
Sick enough to require ICU, consider if hospitilized

26
Q

When would you transition to oral therapy in hospital when IV is started? (2)

A

After evidence of improvement AND blood cultures, If done, are negative (72hrs)

27
Q

When would we need to consider MSSA in cellulitis (3)

A

Purulence
Penetrating trauma
ICU

28
Q

Which drugs are NOT effective for cellulitis? (3)

A

Aminoglycosides
Metronidazole
Nitrofuratnoin, Fosfomycin (only cover uropathogens)

29
Q

Which abx has to be given in an empty stomach? (2)

A

Penicillin
Cloxacillin

30
Q

Which abx is only given IV? (3)

A

Pipercillin + tazo
Carbapenems
Vancomycin

31
Q

Which abx in nephrotoxic

A

Vancomycin

32
Q

Which abx has thrombocytopenia as a side effect if used longer than 14 days?

A

Linezolid

33
Q

Which of the following abx causes hyperkalemia

A

Septra

34
Q

Which abx has the least evidence in cellulitis

A

Doxycycline

35
Q

Which abx has over 10% resistance in cellulitis

A

Macrolides (azithryomycin, clarithryomycin)
Fluroquinolones (levofloxacin, moxiflocacin, clarithromycin)

36
Q

Which abx can cause c diff

A

Clindamycin
Fluroquinolones (levofloxacin, moxiflocacin, clarithromycin)

37
Q

What is outpatient first line for cellulitis

A

Amoxicillin
Penicillin
Cloxacillin
Cephalexin (1st gen)
cefadroxil (1st gen)
Septra

38
Q

What is first line for inpatient who requires IV

A

Cefazolin (no septra due to large dilution requirement, will increase fluid)

39
Q

What abx would you recommend if they have delayed HSR (type 4) to beta-lactam

A

IV Clindamycin

40
Q

What are reasons where MSSA needs to be covered

A
  1. Penetrating trauma
  2. ICU (infection bad enough)
  3. Purulence
41
Q

If MSSA is suspected what drugs CAN’T we use? (3) (unsure)

A

Penicillin
Amp/Amoxicillin (no BLI)
Piperacillin

42
Q

What are risk factors for MRSA? (4)
Consider when?

A
  • Crowded living conditions (prison, homeless, indigenous reserve) OR
  • Recent hospitalization
  • Recent travel (longer trips, trips to USA)
  • IV drug user

Consider:
(only consider if MSSA criteria is ALSO met)

43
Q

What drugs are used if MRSA suspected?

A

ORAL Septra, doxycycline

IV Vancomycin

44
Q

What to monitor for cellulitis therapy ()
Dermatological (3)
Systemic (1)

A

Dermatological sx:
- Redness: to worsen + spread in first 24 hours (with effective antibiotic - as bacteria is releasing toxins when it dies)
- Intensity of redness goes down BEFORE spread stops
- Inflammation: can continue to spread for ≤72 hours

Systemic sx:
- fever up to 72 hours (usually at least 48 hours)

45
Q

What is considered treatment failure in cellulitis (2) How do you assess?

A
  • Inflammation spreading for >72 hours (assess by marking the borders before treatment)
  • New or worsening systemic sx after 24 hours
46
Q

What does classic escalation of therapy on day 3 mean?

A

Very common for therapies to get escalated on Day 3.
This is unnecessary, as it’s likely because OT/PT made patient walk around after improvement.

47
Q

What is usually the duration of therapy

A

5-7 days
- excluding bacteremia or extensive disease

48
Q

T/F Clinical endpoint is resolution of erythema

A

False
- return to normal can take weeks or months

49
Q

What to do upon treatment failure (3)

A
  1. Check for deeper infection (fascia/muscle/bone)
    1. Re-evaluate likely pathogens: consider VRSA, microbiological modifier (animal bite, rock climbing, etc…)
      Consider alternative diagnosis
50
Q

How do we prevent recurrences of cellulitis? (4)

A
  • Moisturize: prevent dryness/cracking
  • But avoid excessive moisture
  • Look out for Tinea Pedis (Athlete’s foot): (microbreaks in the skin could be allowing bugs to be let in)
  • Treat lymphedema and chronic venous insufficiency
    (Elevation, reduce Sodium intake, Compression stockings)
51
Q

When is chronic prophylaxis needed?
Treatment Options (3)
How often to reassess?

A

Needed when:
- Recurrent infection (2 in 6 months or 3 in 12 months)

When to consider:
- only after implementing other risk reduction strategies

What to use:
* PO: Penicillin V or erythromycin BID
* IM: Benzathine Penicillin Q15D

Reassess appropriateness: annually

52
Q

Which drugs are low risk for c. diff (3)

A
  • Septra
  • macrolides
  • doxycycline
  • aminoglycosides

IPFC 5 (10 decks)

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