Skin, Soft Tissue Infection Flashcards
What percentage of cat bites become infected compared to dog bites?
80% vs 5%
What is empiric treatment for dog or cat bites?
Amoxicillin-Clavulanate
What are the most common infectious organisms in a human bite? (7)
- Viridins strep 100%
- Bacteroides 82%
- Staph epidermidis 53%
- Corynebacterium 41%
- Staph aureus 29%
- Peptostreptococcus 26%
- Eikenella 15%
What are two vaccine-able disease that always need to be considered with animal bites?
- Tetanus
- Rabies
What are the conditions when a bite would be treated for tetanus?
- Vaccine: minor wound and no vaccine in last 10 years or major wound and no vaccine in last 5 years
- Tetanus Ig: major wound and has not had at least 3 vaccine doses
What is the treatment plan if an animal bite might have passed on rabies?
- Rabies Ig around the wound
- Rabies vaccine at day 0, 3, 7 and 14
What organism causes Cat Scratch Disease?
Bartonella henselae
What is the typical and atypical presentations of Cat Scratch Disease?
Typical: Local lymphadenitis +/- cutaneous lesions several days after exposure that can last 1-3 weeks
Atypical (10%): liver, spleen, ocular, neurological or MSK involvement, fever of unknown origin
What tests are typically used to diagnose Cat Scratch Disease? What would you treat it with?
- Serology (IFA), blood culture, tissue PCR
- Treatment: Azithromycin
What presents as these two classic syndromes:
- triad of tenosynovitis, polyarthritis, dermatitis
- purulent arthritis
Disseminated Gonococcal Infection
What is not common in Disseminated Gonococcal infection?
Urethritis/Cervicitis (but swabs often +ve)
What treatment is used for disseminated gonococcal infection?
Ceftriaxone + Doxycycline x 7 days
Don’t forget to Tx partners!
What is the most common cause of septic arthritis?
Hematological spread > trauma/bite > post-surgery > direct spread from osteomyelitis
What is the most common organism that causes septic arthritis?
Staph aureus
What is the treatment for septic arthritis?
- IV antibiotics based on Gram stain x 4 weeks making sure to cover Staph
- Joint aspiration in all cases, surgical drainage in hip or prosthetic infection
What is Ludwig’s Angina?
Cellulitis of the submandibular/sublingual spaces
What does Ludwig’s Angina almost always result from?
- Oral infection of 2nd or 3rd molars
- 80% of patients report tooth pain or recent dental work
How do you manage Ludwig’s Angina?
- Manage and protect airway (1/3 of cases require intubation)
- IV antibiotics based on organism
- Surgical evalualtion
- CT scan to evaluate abscess and extent of spread
What are the two most common causes of impetigo?
- S. aureus
- Group A strep
What are the two types of impetigo and their most obvious clinical feature?
Bullous (vesicles) and non-bullous (golden crust)
What are some risk factors for having a diabetic foot infection? (7)
- Previous amputation
- Wound extending to bone
- Peripheral vascular disease
- Ulcer duration >30days
- Loss of sensation
- History of recurrent ulcers
- Wound caused by trauma
Would you need to culture a minor infection if the patient has not received antibiotics within the last month?
No
If you are treating a foot infection in a patient that HAS received antibiotics in the past month, what modifications to antibiotic therapy must you make?
Cover gram negative rods
What is the presentation of a mild infection?
Local infection involving only the skin and subcutaneous tissue. If erythema is present, must be <2 cm around the wound.
What is the presentation of a moderate infection?
Local infection with erythema >2 cm or involving deeper structures than skin and subcutaneous tissues (eg: acbess, osteomyelitis, septic arthritis, faciitis) AND no systemic inflammatory response.
What is the presentation of a severe infection?
Local infection with signs of SIRS, as manifested by 2+ of the following:
- Temperature >38 Celsius or 90 bpm
- RR >20/min or PaCO2 12,000/mcL or 10% immature forms
What is empiric therapy for a severe infection?
Vancomycin and Pipercillin-Tazobactam/4th gen cephalosporin/carbapenem
Rank the most likely places to get cellulitis?
lower extremities > upper extremity > face
What organisms almost always cause cellulitis?
Staph or Strep
What is the presentation of simple cellulitis?
- no fever or systemic symptoms
- Normal WBC count
- Lymphadenopathy or lymphangitis common
What is the presentation of severe cellulitis?
- systemic symptoms
- bullae, hemorrhage, severe swelling
Is needle aspiration or blood cultures useful in mild or localized infections?
No
When is imaging used in cellulitis management?
- Xray if trauma or foreign body is suspected
- Ultrasound to see if abcess or DVT is suspected
What is a very easy technique for tracking the progress of infections?
Draw a line around it with a pen.
What are the general differences between managing mild vs severe cellulitis?
- Mild: Outpatient, oral antibiotics
- Severe: Admit, IV antibiotics
Pt’s presenting with a clenched fist injury are at risk of what?
- Septic joint
- Osteomyelitis
- Give IV antibiotics and get imaging done
What is the DDx for infectious lymphadenopathy?
- S. aureus
- GAS
- Toxoplasmosis
- Viral (HIV, CMV, EBV)
- Bartonella henselae = Cat scratch disease
- Mycobacterium (TB etc.)
Risk factors for septic arthritis
- Old age
- DM
- Joint disease
- Recent joint surgery
- Prosthetic joint
- IVDU
What is the clinical triad for septic arthritis?
- Fever
- Pain
- Decreased ROM in joint
Approach to Dx of septic arthritis
- Aspirate synovial fluid (look for WBCs, Gram stain, culture)
- Blood cultures
- X-ray to rule out osteomyelitis
What organism is the most likely cause of non-bullous and bullous impetigo, as well as scalded skin syndrome?
S. aureus
What is Nikolsky’s Sign?
Skin reddens, fluid collects underneath, and skin rubs off, leaving raw red base (S. aureus toxin mediated skin damage)
Tx for non-bullous impetigo
- Topical antibiotic if localized (mupirocin)
2. Cloxacillin or 1st gen Cephalosporin PO
Tx for bullous impetigo
- PO or IV Cloxacillin, 1st gen Cephalosporin, or Vancomycin (MRSA)
How should the assessment of a diabetic foot ulcer be structured?
- Look at whole pt for signs of systemic illness
- Affected limb/foot (things that may impair healing, PVD)
- The infection itself
Questions to ask about diabetic foot ulcer
- Is there an infection?
- What risk factors are present?
- How severe is the infection?
- How should I manage the infection? What drugs?
How do you rank the severity of a diabetic foot infection?
- No Sx of infection = uninfected
- Infection present (2 of: swelling, erythema, pain, warmth, pus)
- Mild = local infection (skin/SQ, not deeper), erythema < 2 cm
- Moderate = Erythema > 2 cm, or is deeper than SQ, no SIRS
- Severe = local infection with > 2 SIRS criteria
When should a pt be hospitalized with a diabetic foot infection?
- Severe infection
- Moderate infection with poor social support
- Pt’s failing outpatient Tx
Most mild-moderate diabetic foot infections can be Tx with what?
- Agents that cover Strep and Staph
What is Erisypelas?
- Infection limited to upper dermis and superficial lymphatics
- Sharp, raised, and well marked erythema
- Rapid onset, fever, and signs of systemic toxicity
What causes Erisypelas?
- Almost always beta hemolytic strep
- Tx with penicillin V or amoxicillin for outpatient
- Severe or facial involvement = IV benzathine penicillin G in hospital
What is necrotizing fasciitis?
Deep infection of SQ tissue leading to severe destruction of fat and fascia
Causes of necrotizing fasciitis
- Immunocompromised/post-op pt’s = polymicrobial
2. Healthy pt’s = GAS
S/S’s of necrotizing fasciitis
- Systemic signs: fever, tachycardia, hypotension
2. Skin: bullae, disproportionate pain, swelling, erythema, crepitus
Management of necrotizing fasciitis
- Immediate surgical consult
- Cultures (best from surgery)
- IV antibiotics: polymicrobial (Pip-taz and metronidazole or clinda) and for GAS type = Clindamycin + penicillin G
What is the most common infectious agent in cat bites? Dog bites?
Cat: Pastuerella multicoda
Dog: Pasteurella canis
