Osteomyelitis, head, and skin infections

Question 1

Osteomyelitis: The most important first step is to distinguish if it’s skin infection or contiguous spread to bone. How would you differentiate

Answer 1

First line: X-ray - will see elevation of periosteum
- Will be normal in first two weeks

Second line: MRI (if X-ray was negative)

Most accurate: Bone biopsy

Question 2

Osteomyelitis: How do you follow treatment if patient is getting better (since no fever and normal white count)

Answer 2

Follow ESR rate

If ESR elevated 4-6 weeks later, do surgical debridement

Question 3

Osteomyelitis: What is the most common organism

Answer 3

Staph

Treatment
MSSA: Oxacillin or nacfillin
MRSA: Vancomycin, linezolid, or daptomycin

HAS TO BE INTRAVENOUS - send to IV center

Question 4

Osteomyelitis: What are other organisms besides staph

Answer 4

Gram negative bacilli: Salmonella and pseudomonas

Question 5

Head and neck: There is otitis externa, malignant otitis externa, and otitis media

Answer 5

Good enough

Question 6

Head and neck: What is otitis externa

Answer 6

Associated with swimming and foreign objects, diagnosis based on exam, treatment is ofloxacin or polymixin/neomycin

Add hydrocortisone to decrease swelling

Add acetic acid and water solution to re-acidify the ear

Question 7

Head and neck: What is malignant otitis externa

Answer 7

Osteomyelitis of skull from pseudomonas that happens in DIABETICS

Diagnosis same as osteomyelitis (x-ray, MRI, bone biopsy/culture)

Treatment: Surgical debridement and antibiotics against pseudomonas

Question 8

Head and neck: Otitis media

Answer 8

Diagnosed on physical exam, treatment is amoxicillin for 7-10 days

Most accurate test: Tympanocentesis and aspirate of tympanic membrane for culture - rarely necessary

If it does not improve in three days, switch the antibiotic to augmentin, erythromycin

Question 9

Head and neck: Sinusitis diagnosis

Answer 9

Initial test: X-ray

Best test: sinus aspirate for culture (better than CT and MRI)

Question 10

Head and neck: Sinusitis treatment

Answer 10

Viral sinusitis: Inhaled corticosteroids
- Switch to antibiotics if failure after 72 hours

Bacteria sinusitis: Amoxicillin
Only if fever or pain, used 7 days of decongestants without improvement, and purulent nasal discharge

Same organisms and treatment as otitis media

Question 11

Head and neck: Pharyngitis diagnosis and treatment

Answer 11

Symptoms: Sore throat, exudate, adenopathy, but no cough

Diagnosis: Rapid strep test (can be done alone in adults, need culture too in children)

Treatment: Penicillin or amoxicillin (same as bacterial sinusitis and otitis media)

Question 12

The three skin conditions you will come across are impetigo, erysipelas, and cellulitis. What is the difference between the three

Answer 12

Impetigo: Never make microbiological diagnosis. Most superficial - that’s why you get weeping, crusting, oozing (honey colored lesions)

Erysipelas: Group A strep infection, very hot and red, usually on face

Cellulitis: Staph and strep equal. Warm, red, swollen, tender skin

Question 13

What is the treatment strategy for all three skin conditions: Impetigo, erysipelas, and cellulitis

Answer 13

1. Topical mupirocin or retapamulin - impetigo
2. Oral dicloxacillin (MSSA) and cephalexin (MSSA) - impetigo, erysipelas, cellulitis
3. IV oxacillin, nafcillin, cefazolin (ancef) - cellulitis

Pearls

1. Topicals useless for erysipelas and cellulitis
2. Once organism confirmed in erysipelas, switch to penicillin
3. If cellulitis is in lower leg, must get Doppler to rule out clot since they look the same

Question 14

What organism is the hair follicle predominantly infected by, and what is the order of infections

Answer 14

Folliculitis

Question 15

What is the treatment for folliculitis and boils and abscesses

Answer 15

Drainage for large infections

Antibiotics for everything else