Skin And Soft Tissue Infections Flashcards
Make sure to cover these learning objections
Bite: 2 options
Diabetic foot ulcer: 3
Nec.fasc: full regimen? Remember, you need to cover everything
Bite
—wash, debride
—usually skin flora i.e staph/strep
—can be mouth flora from animal: pasturella (dogs/cats), Eikenella from humans and Pseudomonas from camels/swans
—amoxicillin-clavulanate (Augmentin) PO x5d
—ampicillin-sulbactam (Unasyn) IV
Diabetic foot ulcer
—sugar control
—debridement
—polymicrobial infection so:
1. Augmentin or Unasyn
2. Ceftriaxone + metronidazole
3. +/- Doxy or TMP/SMX for MRSA coverage
—severe:
1. vanco + piperacillin-tazobactam
2. vanco + cefepime + metro
Necrotizing fasciitis
—non-purulent so think strep but abx should cover for G+, G- and anaerobes:
—Imipenem
—OR Zosyn (G+/- coverage)
—PLUS vanco (for MRSA)
—PLUS Clindamycin for anti toxic effects
—PO if mild, IV if moderate/severe
SSTIs
Three infections that fall under non-purulent and purulent
Which bacteria?
Treatment for mild, moderate and severe? (Broadly speaking)
non-purulent: STREP
—cellulitis
—erysipelas
—necrotising
Purulent: STAPH
—abscess
—furuncle
—carbuncle
Mild: PO abx
Moderate: PO/IV abx
Severe: +SIRS or failure of PO abx/I&D > IV abx
Antibiotics for SSTIs table for reference only
How do you treat beta-hemolytic STREP?
(non-purulent cellulitis)
PO (3)
IV (1)
What are the alternatives?
What is present in 10% of non-purulent infections?
Know the bolded ones
PO beta lactams
1. Dicloxacillin (MSSA coverage)
2. Augmentin: Amox-Clavulanate (augmentin)
3. Cephalexin (MSSA & gram neg)
IV beta lactams
1. Unasyn: Ampicillin/sulbactam (MSSA & gram neg)
2. Cephazolin (bolded at the bottom)
Alternatives
1. Vancomycin IV
2. Clindamycin
3. Note resistance issues with macrolides, doxy, fluoros, TMP/SMX
MSSA is present in 10% of n.p infections. not always necessary to cover but often do
What are MRSA risk factors? (Patient populations)
How will you treat MRSA / purulent cellulitis or abscesses ?
PO and IV
PO
1. Doxy
2. TMP/SMX
3. Clindamycin
!! Remember Doxy and Bactrim don’t cover strep!
IV
1. Vancomycin
2. Clindamycin
Which two antibiotics have come out in the last ten years and have a long half-life and only require a single dose, and covers MRSA?
Chu said don’t need to know the names, just be aware
Dalbavancin
Oritavancin
(Similar to vancomycin)
Although these medications are somewhat restricted
Treatment option for abscesses?
Mild
Moderate
Severe
What do you never JUST treat abscesses with??
Mild: should really only need I&D
Moderate: I&D, culture and PO ABX
Severe: I&D, culture and IV ABX
NEVER treat an abscess w/ just ABX!
How are you going to treat these PO and IV:
Non-purulent / GAS (less common MRSA)
Purulent: MRSA
What about if you want to cover both?
(See notebook)
NP: GAS
—PO cephalexin or dicloxacillin
—IV cefazolin
P: MRSA
—I&D
—PO doxy, TMP/SMX
—IV vanco
If you want to cover both
1. Cephalexin + doxy
2. Cephalexin + TMP/SMX
3. Clindamycin alone
How do you treat superficial SSTIs like impetigo (mild and deep) and folliculitis (3)?
Impetigo
Mild: topical mupriocin
Extensive/deep: PO abx (as w/ cellulitis)
Folliculitis
Warm compress and topical agents (MEC)
Mupirocin, Erythromycin, Clindamycin
or antifungal if applicable
Mupirocin
Active against?
Primary use? 2
—staph including MRSA and strep
—mild strep impetigo
—folliculitis
Bacitracin
Active against? 3
Often combined with? Why?
What does a “triple-antibiotic ointment” contain?
OTC/Rx?
ADRs?
—staph, not reliable for MRSA
—strep and clostridium sp
—combine w/ Polymyxins for gram neg
—triple ointment: + neomycin
—OTC
—contact dermatitis
What is a good clinical response for a SSTI?
When do you see improvement? How many hours does it take
Duration for uncomplicated SSTI?
20% improvement in erythema
Takes 48-72h
5-7 days
What could be some reasons for anti microbial failure or reccurence?
What is cellulitis sometimes confused with?
—not actually an infection, i.e stasis dermatitis
—underlying abscess
—drug/bug mismatch
—PK or PD issues (wrong dosing)
—compliance
—comorbidities (diabetes)
Bite wounds
What do you do first?
In what situations are prophylactic abx indicated? 4
What possible pathogens?
What treatment? 2 (+route & duration)
wash & debride
Prophylax
—i.c patients
—sensitive areas
—puncture wounds
—severe
Pathogens
—cat/dog: pasteurella
—humans: Eikenella
—camels/swans: pseudomonas (cefepime, fluoroquinolones, Zosyn)
ABX:
—Augmentin: amoxicillin/clavulanate PO x5d
—or Unasyn : ampicillin-sulbactam IV
—alternative agents may cover for B/fragilis
Which pathogens are associated with these environmental exposures?
—hot tub folliculitis
—nail salon
—trauma wounds
—seawater
—hot tub folliculitis (pseudomonas)
—nail salon (mycobacterium)
—trauma wounds (clostridium)
—seawater (vibrio vulnificus)
Diabetic foot infection
What in addition to abx?
Moderate Tx? 2 main, 2 additional
Severe Tx? 2 combos
—sugar control, debridement
ABX
—likely to be polymicrobial to include gram neg
Moderate
—amox-clav
—amp-sulbactam
—ceftriaxone + metro
—possible consider doxy, TMP/SMX
Severe
—vanco + piperacillin-tazo (Zosyn)
—vanco + cefepime + metro (G+, pseudo, B.frag)
