Nu 735 SKIN Flashcards
1
Q
Cellultis
What is it ?
A
*** Acute Inflammatory **Condition of skin characerized by Localized:
* Pain, Erythema, Swelling, Heat
* Usualy infection of LE but can be anywhere
2
Q
Cellulitis caused
A
- Indigenous Flora (Colonizing Skin ) or
- Exogenous Bacteria : Wide variety.
- Access Epidermitis: from cracks, abrasions, cuts, burns, bites.
- If skin compromised can develop cellulitis
- MRSA Replacing MSSA inpatien & outpatient settin
*
3
Q
Purulent VS Non-Purulent
A
- Purulet Cellulits: MRSA/MSSA - Focal infection
- Non-Purelent : S Pyogenes > Rapid Spread > Diffuse Associates Lyphagitis
4
Q
Cellulits
*Most common Portal of Entry :
Healthy person LE Due to
A
- **Web intertrigo with fissuring **
-
Tinea Pedis : Complicated By
Intertrigo is not inflammatory skin condition it lead to fungal to** bacterial i**nfection
5
Q
Cellulitis
Most common bacteria
A
> ** Gram positive cocci : **
Group A beta hemolytic &
S. aureus
6
Q
S Pyogenes
A
non -purulent
Rapidly spread
Associate w Lymphagitis
7
Q
Cellulits :
Rare Bacterian
A
**Gram Negative **
**Pseudomonas Aeruginosa **
Occurs in :
* Hospitanlized and Immunocompromized pt
* Steping on Nail : Deep Tissue Injury
* **Pseumomonas = DTI **
8
Q
Cellulitis:
Recurrent
A
**Streptococcal Cellulitsi : Group A, C, or G **
- Venous Statis, Saphenous Venectomy From CABG
- Chronic Lymphedema.
- Lymph node dissection
- Milroy Disease (disease that effect the function of lymphatic System )
9
Q
CEllulits :
Elderly Population
A
With DM and PVD
Group B Step: **Streptoccocus Agalactiae **-
10
Q
Cellulitis Clinical Manifestations
A
Classic Findings:
* Pain, Erythema, Swelling, Heat
* Begins as Small Tender Patch
* Expands over Hours : 6 to 36 HRs
11
Q
Cellulits : Labs
A
- Leukocytosis
- At least Neutrophilia
12
Q
B/L Cellulitis
A
- Very uncommon
- DDx Statis Dermatitis
- **Consider Crytococcal **
13
Q
Worsening Infection
A
- Chills, Fever, malaise
- Lymphagtitis and Lymphdenopathy
14
Q
Cellulitis : Complications
A
Septicemia
And
Shock
14
Q
Cellultis :
Animal or Human Bites
A
- Augementin
- Ampicillin
- Cefoxitin ( 2nd Generation )
14
Q
Cellulits TX:
Empirical TX
A
- Cover for both Strep and Steph : Gm +
* - Cefazolin 1gram TID (1st generation Cef) OR
- Rocephin
15
Q
Cellulitis DX
A
- Clinical Observation:
- R/O Statis Dermatitis , DVT vs Cellulitis
- Definitive DX: Wound culture and Gram’s stain( from wound)
- Skip Biopsy: Immunocompromised pt looking for uncommon Bacteria
*
16
Q
Cellulits :
Pseudomonas Aeroginosa
A
**** Most common Penetrating injury Stepping on Nail
**ABG Coverage: **
** Gram negative **
- **Aminoglycoside **(Gentamycin )
- 3rd gen Cephalosporin (Cefriaxone; Cefotaxine, Cephaxide)
- Semi-Synthetic PNC (Zosyn )
- Fluoroquinolone (Ciprofloxacin; Levofloxacin )
- For 7 to 10 days
17
Q
Diabetic Foot Ulcer
Overview
A
- Leading cause of Non-Traumatic LE ambutation
- Major source of Morbidity
18
Q
DM Ulcer :
**Reason of Increased incidence of ulcer Involves
Multiple Factors **
A
* Neuropathy & Abnormal foot Biomechanics : Interferes with normal Protective Mechanisms
* PAD & Poor wound Healing : Impeded Integrity
19
Q
DM Ulcers: Risk Factors
A
Male, DM > 10 yrs, smoking, Visual impairment, Poor Glycemic control, Dialsys
**Attentin to Risk Factors :
PVd, smoking, Dyslipidemia, HTN, Obesity, Glycemic Control: Impove
20
Q
DM Ulcers: Common Areas
A
Great Toe
Metatarsophlangeal
Plantar
14 to 24% Undergo Amputation
20
Q
DM Foot Ulcers:
Clinical Findings
A
- Asymptomatic vs Symptomatic
- Plantar Surgace: Most common Site
- Nerupatic Ulcer vs Infection (Cellulitis around )
- Gas Gangrene w/c Clostriial
21
Q
DU: Infectious Etiology
A
Multiple Organisms:
* **Aerobic Gram-positive Cocci **: Most common (Staphylococus species; Streptococcus species; Group A, B, MRSA )
* Aerobic & Anaerobic Gram negative Bacilli
Empirical Coverrege
21
DM Ulcer : TX Plan
* Identification of High-Risk Patient
* Education and Prevention
* Anual Foot Exam
* Screening the Asymtomatic for PAD ( > 50 yrs with DM; ABI (Ankle Brakial Index ultrasound check for PVD for high risk pt
22
DM: Patient Education
* Daily Inspection feet and fot Hygiene
* Avoidance of self TX
* Prompt consultation (podiatry)
23
DM Ulcer: Risk Factor Modifications
* Orthotic Shoes and Devices
* Callus Management and nail Care
* Prophylactic Measures: Reduce abnormal bone abnormalities pressure
24
DM Ulcer DX
I**nitial Imaging **
* Plain Radiography (XRAY )
* MRI (R/O Osteomyelitis)
* Nuclear Medicine tagged WBC ( if pt has metal in a body)
laboratry: CBC, CMP, Wound & BC
25
DM Ulcer
DX: Mild Infection tx
PO **Cephlosporin (Augmentin ) **
26
DM Ulcer: Prior Hx MRSA
Clindamycin (Baware C/Diff)
Docycyline or Bacrim (watch DM pt can lead to AKI )
27
DM Ulcer: Severe Cases
**Empiric Coverage IV ABT: **
Cover : Staph, Strep, Gram negative Aerobic and Anaerobes
Vancomycin + Beta Lactam Inhibitors (Zosyn or Cephapin ) or Carbapenem
**Vancomycin + Fluroquinolone (Ciprofloxacin; Levoflaxacin target (gm - ) + Flagyl (anarobic coverage)
*** Vancomycin and Cephapime (4th ) most common pharmacy does
28
Dm Ulcer: Infectious Etiology
Multiple Organisms :
* **Aerobic Gram (+) Cocci **- most common (Stephyloccocus species, Steptococcus Species, A+ B , MRSA )
* Aerobic + Anaerobic Gr (-) Bacilli
29
Foot Osemoyelitis :
Epidemiology
* DM, PAD, Perepheral Neuropathy, post Surgery
* 20 to 60% will get Oseomyelitis
30
31
Foot Osteomyelitis : Entry
**Exogeneous insult**
* Complicatio of deep pressure Ulcers
* Impaire wound healing after Surgery
* DM Incidence 30 to 40 cases /1000/year
* Osteomyeltis : 20 to 60% will get confirmed Osteomyeltis
* Increase risk for amputation
*
32
Foot Osteomylitis :
Most common Pathogens
S. Aureous
Anaerobes
Various gram Negative Bacilli
33
Osteomyelitis DX
**MRI : **
80 to 100% Sensitivity
80to 90% Specificity
Probe to bone : prediction
34
Ostemyeltitis TX
* Antibiotics based on Bone Culture
* Empiric Therapy if no Culture
* Gm + considere MRSA
*** Risk for P Aeruginosa**: Antipsedumonal Covereage
35
Osteo :
Risk for P aeroginosa
antipseumomonal coverage (exposed to water )
* Zosyn
* CEFEPIME
36
Osteo
ABT within last month
Clindomysin and Fluoroquinolon (Levo and cipro)
37
Osteo
lenth of ABT
Wound debridement plus 4 to 6 wks ABT
Dead bone still present : Long term ABX for 3 month
38
Periprosthetic Joint Infectious (PJI)
Overview
******Impalnted Material **
* Highly susceptible to Local Infection
* Exogeneous or Hetogenous insult
* Covered with Host Proteins : Favors Staphylococci adherence
* Form a biofilm
39
PJI
Common Organism
Stephlococcus auresous and Coagulase
Cutibaterium Acnes
40
PJI
Cutibaterium Acnes
Causes 1/3 PJI shoulder infection
Associate with cronic PJI
41
PJI : Traditional Classification
* Early: <3 months after implant
* Delayed: 3 to 24 months after Implant
* Late: > 2 yrs after Implant
42
PJI : Hematogenous
* S aureus
* New onset of Pain
* No initial inflammatory signs
* Sepsis Syndrome dominates clinical Pictur
43
PJI Chronic
Joint effusion
Local and chronic pain
Implant loosening
Sinus tract
44
PJI
DX
labs: CBC, CRP, ESR
Arthrocentesis : for Synovial Fluid Analaysis
*Early onset PJI: > 10,000cells
* Late onsetPJI: > 3000 cell
Obtain Culture
45
PJI
XRAY and CT and MRI
* **XRAY: Identify effusion; Abnormal findings **
* **CT and MRI: **
* Sinus tract
* Detect soft tissue infection
* Prosthetic loosening
* Bone erosion
* Effusion
Three Phase Bone Scan : Hightly Sensitive, not specific
46
PJI
Diagnosis : Major
one major critieria EXist
Two +
Periprosthetic Cultures With
Phenotypically Identical Organisms
A sinus Tract communicating with the Joint
47
PJI Minor Criteria
* Elevated CRP and ESR
* Elevated Synovial fluids WBC count or ++
* Change o Leukocyte Esterase test strip
* Elevated synovial fluids
* Presence of purulence in the affected joint
* Positive Histolici analysis of periprosthetic tissue
* A single positive culture
48
PJI Treatment
Rifampin +Nafcillin +Vancomycin
Rifampin - W biofilm activity
Gram negative - Fluoroquinolones - Activity agoinst biofilms
49
Sternal Osteomyelitis
OVerview
* Low Incidence
* Primarily after Sternal surgery
*** Caused: Exogeneous Organisms rarely Hematogenous Organism **
* **Exogeneous Organisms : ( Sternal trauma, sterna fracture and Manubriosternal septic arthritis
* Rarely caused by Hematogenous seeding
50
Sternal Osteomyelitis
Risk Factors
DM, Obesity, HIV, CRF, ETOH, Liver Cirrhosis
Radiotherapy
Cardiopulmonary Resuscitation
Emergency Surgery
Bilaterina intanal mammary is
Re-Exploration
51
Sternal Osteomyelitis
Causative Organisms or pathogens
*** Staphlococcus Aureus : **Most common Hematogenous
Caugulase-negative Staphylococci: Sternal wire Infection
Fungal infections : candida
Pseudomanana aerogunosa : IVDA
Salmonella : Siclel cell Anemia
M Tuberculosis : Endemic areas or prefiously infected
Plymicrobial Infections : Indicative of exogenous seperinfection
52
Sternal Osteomyeltitis
Sign and symptoms
Fever
Increased Local pain
Erythema
wound discharge
sternal instability
53
Sternal Ostemyelitis
Complicatiosns
**Contiguous mediastritnitis **
High mortality
Life threateming condition
inflammatiion of mediastrinal structures
Physiologic compromise bleeding and sepsis
54
Sternal Osteomyeltis
Diagnosis
Labs: CBC, BMP, ESR, CRP, BC
**Tissue Sampling needed: Three sample needed
1. deep Biopsies
2. Differenctiate b/w colonization and infection
3. Superficial swabs: Non -diagnosis and misleading
**Imaging: > MRI > Gold Standard > Detection of Osteomyelitis
55
Sternal Osteomyeltitis Threatment Plan
Antibiotic Plan :
* Staphylococci spp
* Nafcillin + Rifampin
* MRSA: add Vanco or Daptomycin
* Narrow antibiotics with confirmed pathogens
56
Sternal Osteomyelitis
Duration of therapy
* Without Hardware Involvement : Six Weeks Course
* Sternal Wires Infection: 3 Months
57
Sternal Osteomyelitis
Primary Sternal Osteomyeltis : treatment without surgery
Secondary sternal ostemomyeltis : Requires debridement
58
Necrotizing FAscitis
Overview
* Extensive Necrosis of Subcutaneous** Tissue and FAscia
* Common Organisms: Group A Streptococci + Mix Facultative Anaerobic Flora
* Mixed Flora Develop gas pattern
59
Necrotizing Fascitis
Risk Factors
DM
IVDA
Chronic liver
Renal disease
Malignanacy
Mild Lesaration
60
****Necrotizing Facititis
**Mortality Rate **
15 to 34 %
>70% with Toxic Shock
61
Necrotizing Fascititis
Clinical manifestations
* Toxic appearance
* Buloe
* Skin Necrosis
* Rhabdomyolysis or DC
* Severe pain an fever
* Soft tissue edema and erythema
* Red, hot, skiny, swollen and tender
*** Pain Decreases: ** Thrombosis of small vessels
62
Clostridium Perfingenis
Necrotizing FAscitis
Extremely Toxic
Hight mortality rate
48 hours rapid tissue invasion and sytemic toxicity
63
Necrotizing Fascititis
Tx
IVF
Vancomycin +
Clindomycin +
Gentamicin
64
Gas Gancrene
Bacterian
Clostridium Pertringens Produce
65
Gas Gancgrene TX
PNC G + Clindomycin
PCN Allergy: Cefaxitin plus Clindomycin
Vanco and Flagyl Surgery
Tru Immergyr : Debritins
Hypeberic : can inhibit grown
66
Myositis
* Considered Tropical disease
* Present in temperate climates
* Emergence of HIV Infection
67
Infecious Myositis
****Acute, Subacute, or Chronic Infection
Viral Invalvement
* Influenza, Coxsackievirus type B, dengue
68
Parasitic Invasion
Trichinellosis
Cysticerosis
Toxoplasmosis
69
Pyomyositis
Bacterial Infection
S aureus
70
Pleurdynia
Definition of pain due to infection
**Coxsackievirus B **
70
Myositis
Clinical Findings
Myalgia
Abcess formation
Myositis
Pleurodynia :
* Hallmark severe muschle pain
* Fever
* Malaise
* Headaches
71
Myositis
Complications
Acute Rhabdomyolysis
Clotridial spp or Streptococcal myositis
Influenza virus, echoviurs, Legionella
Toxic shock Syndrome: ****
Toxic shock
72
Myostitis
DX
**Imaging**
* Soft tissue CT and MRI
* Determine Depth of infection
* Identify abscess
* **Invasive Procedures
**Abscess drainage
Asipiration of leading edge
Punch biopsy with frozen section
False negative resutls 80% cases
**Labss **
Culture and Gram's stain abscess
Viral culture
PCR
Serologic evaluation of viral antibodies
73
74
Viral myositis
Supportive care
bedrest
IVF
75
Burns:
4 types
1.** Thermal Burns**
External heat Source
Risk of Toxix smoke inhalation
2. **Radiation Burns **
Prolonged Exposed to Solar UV Radiation
3. **Chemical Burns **
4.** Elecrical Burns **
76
Burn Depth
* **Superficial( formely 1st degree)
Limited to Epedemis
Apears Red or Gray
Demonstrate excellent capillary Refill and hot blistered initially
**Partial Thinckness ( formely 2nd degree )
Involve part of dermis and czn be superficial or deep
Blisnte and wet
***Full thinckness (3drd degee) **
Extend thrugh entire dermis and underlying fat
loss of adrenal structures
Appears as white -yellow, may have black charred appearance
Stiff dry skn does not bleed cataneuous senastion is lost
77
