E2.3 Flashcards
Common Signs and symptoms of systemic infection
Temperature > 38 C or < 36 C
Heart Rate > 90 BPM (tachycardia)
Respiratory Rate > 24 breaths/min (tachypnea)
WBC > 12,000 or < 4000 cells/mm3
Impetigo is common
Among pediatric pts.
In close quarters
In summer months
Impetigo signs/sypmtoms
Small, tender papule, minor skin disruption
–“ honey crusted” with a serous discharge
Itch, minimal pain and surrounding erythema
Local lymphadenopathy
Fever is uncommon
Leukocytosis in about 50% of pts.
Mild to moderate impetigo treatment
Topical agents
Applied twice daily for 5 days
Bactroban (mupirocin)
Altabax (retapamulin)
Moderate to Severe, site of infection impetigo treatment
Oral agents
Taken for 7 days
Cephalexin
Dicloxacillin
MRSA suspected or known Impetigo treatment
Bactrim
Cleocin
Doxycycline
Ecthyma
the infection reaches deeper to the dermis layer than impetigo
As lesions heal, scarring is common
Ecthyma diagnosis
clinical presentation
Gram stain with culture and sensitivity (C&S) may be performed but not typical
How is Ecthyma treated?
Empiric coverage is usually directed toward MSSA and S. pyogenes
Topical agents are not recommended
Oral agents for 7 days
-Cephalexin or dicloxacillin
MRSA suspected or culture results known
-Bactrim, Cleocin, or doxycycline
ABSSSI means
Acute bacterial skin and skin-structure infections
How does the FDA define ABSSI?
cellulitis/erysipelas, major skin infections and wound infections with a lesion surface area of ≥ 75 cm2 (area of redness, induration, and edema)
What is the most common cause of purulent skin infections in the U.S.?
MRSA
Purulent SSTI
Furuncle
Carbuncle
Abscess
Furuncle
a.k.a. boil
Hair follicle infection extending through the dermis into the subcutaneous tissue
Carbuncle
Involves several hair follicles and is typically deeper into the tissue
Purulence typically drains from more than one orifice
Typically found on the back of the neck; diabetic patients
Abscess
Collected pus pocket within the dermis and deeper skin layers
Painful, movable nodule with a circular rim of edematous swelling
How are staph skin infections diagnosed?
Based on clinical presentation
Gram stain and C&S testing recommended for large furuncles, carbuncles, and abscesses
Not always necessary
Recurrent abscesses need?
I/D immediately with C&S testing
Mild purulent SSTI classification and treatment
No signs and symptoms of systemic infection
Treatment: Incision & Drainage (I&D) alone
Most furuncles will drain with moist heat
Amox/Clav. (Augmentin)
Moderate purulent SSTI classification and treatment
Signs and symptoms of systemic infection
Treatment: I&D with Culture & Sensitivity (C&S)
Empiric: Bactrim or Doxycycline (PO)
MRSA & MSSA likely pathogens
MSSA- cephalexin and dicloxacillin
Severe purulent SSTI classification and treatment
Signs and symptoms of systemic infection
Immunocompromised state
I/D and oral antimicrobial failure
Treatment
I&D with C&S
Empiric: IV antimicrobial covering MRSA
Targeted MSSA: Cefazolin, Cleocin, Nafcillin
Duration of purulent SSTI treatment
5-14 days, commonly 7-10 days
Severity
Bloodstream infection (BSI) longer
Reasons to add antibiotics to I&D
Site of abscess inhibits draining
Septic phlebitis
Extremities of age
Immunocompromised
Lack of response to I&D alone
Extensive disease or severity
Signs of systemic infection
Risk factors for CA-MRSA
Athletic teams, dorms, military, inmates, day care
IVDU (intravenous drug users)
Tattoo, piercing
Homeless
HIV infection
Same sex partners (men especially)
Risk factors for HA-MRSA
Indwelling catheters
Dialysis (HD)
Extended hospital stay
ICU admission or other closed units especially
Long-term antibiotic use
Recurrent SSTI caused by MRSA is defined as
2 or more episodes within a 6-mth period at different sites
Strategies to combat recurrent SSTI by MRSA
Clean commonly touched surfaces
-doorknobs, toilets, counters, etc.
Decontamination
-Daily towels, sheets, and clothing
Decolonization
-Nasal mupirocin twice daily for 5-10 days
+/- one of the following:
-antiseptic solution (chlorhexidine) for 5-14 days
-Diluted bleach bath (1tsp bleach /1 gal of water) soaking 15 minutes twice daily for 3 months
MRSA preferred route agents
Bactrim (PO)
Cleocin (PO/IV)
Doxycycline (PO/IV)
Minocycline (PO)
MRSA alternative agent
Rifampin (PO)
MRSA drug of choice
Cubicin (IV)
Vancomycin (IV)
MRSA alternative long acting
Televancin (IV)
Dalvance (IV)
Orbactiv (IV)
MRSA alternative short acting
Teflaro (IV)
MRSA alternative short-acting (IV and PO)
Delafloxacin (PO/IV)
Omadacycline (PO/IV)
Sivextro (PO/IV)
Zyvox (PO/IV)
Cellulitis
Inflammation of the epidermis, dermis, and/or superficial fascia that rapidly spreads
Borders are not clearly defined or elevated
Can affect any body part
Erysipelas
has raised borders and clear demarcated margin.
Common sites are legs and feet; may be seen on face
Cellulitis and Erysipelas risk factors
(skin integrity compromised)
Skin conditions
Surgery
Minor trauma including abrasions or ulcerations
Peripheral vascular disease (PVD)
Obesity
Diagnosis of Cellulitis and Erysipelas
Cultures and biopsies are generally not recommended
Exceptions (animal bite wounds, cancer pts. recieving chemo or w/malignancies, immersion injuries, neutropenia, severe cell-mediated immunodeficiency)
Mild Cellulitis and Erysipelas classification and treatment
No sign or symptoms (s/sx) of systemic infection
Empiric treatment: PO agents
Pen VK, Keflex, Cleocin, Dicloxacillin
Moderate Cellulitis and Erysipelas classification and treatment
S/sx of systemic infection
Empiric treatment: IV agents
Pen G, Cefazolin, Cleocin, Rocephin
MRSA agents if risk factors present
Duration of cellulitis and erysipelas treatment
7-10 days recommended but lack of data to support
Severe Cellulitis and Erysipelas classification and treatment
Oral antimicrobial agent failure, S/sx of systemic infection. Signs of deeper infection, skin sloughing present, HTN, organ dysfunction present.
Immediate evaluation for surgical intervention to identify necrotizing infections.
Empiric therapy: Vanc w/ one of the following: Zosyn, Primaxin, Merrem. 1st line is Vanc+Zosyn
What is necrotizing fasciitis
Flesh eating bacteria
High mortality d/t rapid tissue destruction
Sub-Q infection that may involve superficial fascia
Develops from skin cut d/t trauma/surgery
May look like cellulitis but progresses faster
Most cases are in the lower extremities
Necrotizing fasciitis risk factors
Poor veins or insufficiency w/edema
IVDU
DM
Vascular disease
Ulcers
Necrotizing fasciitis signs and symptoms
Severe pain, lack of response to initial antibiotics, sub-q is hard to touch, systemic signs of infection present, altered mental status, edema and tenderness deeper than cutaneous erythema, bullous lesions, skin necrosis
Diagnosis of necrotizing fasciitis
surgical inspection is primary method (swollen gray with stringy necrosis, possible brownish thin exudate w/ no pus)
CT or MRI show fascia plane edema
Gram stain of deep tissue and/or direct-needle aspiration for C&S may be performed
Blood cultures suggested
Necrotizing fasciitis treatment
Immediate surgical excision is primary treatment
Daily surgical evaluation for need of more debridement until no longer needed
IV fluids d/t loos of fluids through wounds
Necrotizing fasciitis antibiotic treatment for streptococcus pyogenes
Penicillin+Cleocin
Necrotizing fasciitis antibiotic treatment for Vibrio vulnificus
Doxycycline + Rocephin, Claforan or Fortaz
Necrotizing fasciitis antibiotic treatment for Aeromonas hydrophilia
Doxycycline + Cipro or Rocephin
Necrotizing fasciitis empiric antimicrobial therapy
Cleocin to suppress toxin production in S. pyogenes
MRSA IV agent (Vanc, Cubicin, Zyvox) along with one of the following: Zosyn, merrem, Invanz, Primaxin, Flagyl +Rocephin, Cipro, or Levaquin
Non-Pharmacological Treatment of SSSI
Skin hygiene
Elevation of limb with infection (minimizes edema)
Cold compress (decreases local inflammation)
Wound care for chronic wounds
When should you treat bite wounds without initial signs of infection?
Advanced liver disease, spleen is absent, immunocompromised, have moderate to severe injuries, injuries to periosteum joint capsule face hands or feet
