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by tbruno


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Primary Skin infections
Impetigo
Cellulitis
Lymphangitis
Erysipelas
Necrotizing fasciitis
Furuncle/Carbuncle
Abcess
Secondayr Skin infections
Diabetic foot
Pressure sores
Bite wounds
Burn wounds
Impetigo
Superfical cellulities
Initiated with scratches/bits, chicken pox lesions
Highly communicable

Purulent crusted look
Pruiritic

Can culture form base -Recomended
Impetigo Tx
Topical Mupirocin 2% or Retapamulin 1% (Atabax) BID 5 days

If numerous leasions or outbreak oral therapy

Dicloxaccilin or Cephalosproin 7days

GABHS Penicillin 7 days

MRSA Clinda, doxy or TMP/SMX
Purulent infections
Furuncle

Carbuncle

Abcess
Non purulent infections
Cellulitis

Erysipelas

Necrotizing infecions
Cellulitis and Erysipelas
Diffuse spreading skin infections

Distinction relates to depth of inflammation
-Cellulities affects deeper dermis and subcutaneous fat
-Erysipelas affets the upper derrmis incluidng superficial lyphatics

Diffictul to differentiate clincily
Cellulitis Clinical features
Erythema, warmth, edema at site

Borders of inection not clearly demarcated

Tenderness at site

Additional less characteristic finding
-regional lymphadenopathy
-local abcessess

Systemic findings
-Fever, malaise, chills, lukocytosis
Cellulitis
Common sites
-Extremities
-Head and neck
-Torso

Differential
-Contact dermatitis (not warm)
-Gout
-Herpes zoster
Erysipelas Presentation
Clinical Features
-raised lesion with sharply demarcated borders
-bright red, edemoatus, inurated
-Painful
-fever, leukocytosis
Erysipelas Risk groups
More likely on lower extremites

Infants/young children and elderly
Preceding respiratory infection (facial)
Nephrotic syndrome
Microbiology Cellulitis
Group A Streptococcus
Staphyloccocus aureus
Additonal neonates
-group B streptococcus
Additional children
-Streptococcus pneumoniae
Hospitalized
-Staphylococcus epidermidis
-Gram - pathogens
Microbiology Erysipelas
Group A Streptococcus
Rarer
-Staphylococcus aureus
-Group C, G, B Streptococcus
CA-MRSA clincial Presentation
Insect or spider bite like appearence
Folliculitis
Furucnle, Carbuncle (Boil)
Abscess

Callulitis
Impetigo
Infected would
Necrotizing pneumonia
Laboratories and Cultures
WBC with differential
Neelds aspirate of inflamed skin or leading edge culture
Blood culutre
Mild - Moderate Non-Purulent Infections
Mild
-Typical Cellulitis with no focus of purulence

Moderate
-Typical cellulitis/erysipelas with systemic signs of infection
--Fever malaise
Sever Non-Purulent Infections
Failed oral antibiotic therapy

Systemic signs of infection
-Fever
-Tachycardiea
-Tachypnea
-Abnormal WBC
-Immunocompromise

Deeper skin signs
-Bullae
-Skin sloughing
-Hypotension
-Organ dysfunction
Mild Non-Purulent SSTI's Tx celulitus
Dicloxacillin orial
Cephalexin
Penicillin oral -lose MSSA coverage
Clindamycin - also covers most CA-MRSA

5 days

ative: Amoxicillin +/- clavulanate
Mild non-purulent SSTIs Therapy
Penicillin VK
Amoxicillin

7-10days

Alternatives for allergy-clindamycin
Moderate Non-Purulent SSTIs tx
IV initially indicated
Cefazolin
Clindamycin (covers most CA-MRSA)
Ceftriaxone
Penicillin G

Consider if Previous MRSA or IV drug abuser
Sever Non-Purulent SSTIs Therapy
Empiric therapy is broad and should cover MRSA

Empiric IV
Vanc + Piperacillin/Taxobactam

Alternatives
-Imipenem or Meropenem
Necrotizing SSTIs definition
Definition
-Severe infection
Involves sub Q tissue

Rapidly progresses
Necrotizing SSTI
Initially hard to differentiate vs Cellulitis
Edema
Skin discoluration of gangrene
Pain disproportionate to physical findings
Skin blisters or bullae
Systemic symptoms/signs incuding high fever, siorientation, shock
Necrotizing SSTIs Types
Type 1
Relatd to trama, IVDA, dcubitus, Ulcers
-Ploymicrobrial

Type 2
Releated to minor trauma
-2/3 lower extremity
-Monomicrobial
Type 1 Polymicrobial
Vancomycin IV + Pipercillin/Tazobactam IV
Type 2 Invasive GABHS
Penicillin IV + Clindamycin IV

-Clindamycin results in toxin suppresion and modualation of cytokin production

-Penicillin covers c/w resistance
Type 2 Vibrio vulnificas
Doxycycline IV + Ceftriaxone IV
Type 2 Aeromonas hydrophila
Doxycycline IV + Ciprofloxacin IV
Type 2 Clostridial SP
Penicilin IV + Clindamycin IV
Aditional Recommendations for Cellulitis
For lower extremity infections, perform careful interdigital to exam
-Evaluate for fissuring, maceration, scaling, if precens decolonize

Systemic corticosteriods in nondiabetic adults

For pts with recurrent cellultis
-Identify and modify predisposing factors
-Consider prophylatic antibiotics (Pen and Erthromycin) for 4-52 weeks if have had 3-4 episode per year despite modifying predisposing factors
Furuncle
Boil

Infection of hair follicle
Inflammoatory nodule with overlying pustule
Carbuncle
Involves several adjacent hair follicles

A coaleced infammatory mass

Typically seen on the back of the neck

More comon in diabetics
Purulent skin infections Severity
Mild
-No systemic
Moderate
-Fever, Malaise

Severe
-Fever
-Tachycardia
-Tachypnea
-Abnormal WBC
-Immunocompromised
Mild Moderate Purulent SSTI-Therapy
Mild abcesses/boils- I&D primary tretment

Moderate infections-empiric therapy
-Also I & D
-Coverage of CA-MRSA recommended
-TMP/SMX
-Doxycycline
Empiric Oral Therapy for CA-MRSA
Trimethoprim-Sulfmthazole

Doxycycline

Clindamycin

Linezolid
Clindamycin
Advantage-has activity against Grpu A Streptococcus

Must be concered if isolate is clindimycin Sensitive and Erythromycin resistant

Use D test
Linezolid
Gm + spectrum including MRSA, VRE, PRSP

100% oral bioavalibilty

Some concern for increasing resistance

High cost-reserved for sever infections

ADRs
-GI
-Rash
-Neutropenia
-Thrombocytopenia (monitor platlets)
-Peripheral neuropathy
Empiric Therapy Severe Purulent SSTIs
IV Vancomycin
IV Daptomycin
Linezolid
IV Telavacin
IV Ceftaroline
Daptomycin (Cubicin)
Semisynthetic cyclic lipopetide antibiotic
Gm + spectrum (including MRSA, VRE, PRSP)
Adult dose 4mg/kg IV q24h
Renal elimination

Do not use for Pneumonia

Eleveate CPK
Not for
Telavancin (Vibativ)
Lipoglycopepetide
Bactericidal agains MRSA, VISA and VRSA
Indicated for cSSTI
10mg/kg IV over 60 inuts q24 7-14days

possibility of fetal harm
ADE: taste disturbance, nausea, nephrotoxicity
Ceftraroline (Teflaro)
Clovers MRSA and GABHS and some G-
Associated with hypersensitivity reaction and c.diffe
10% + Coombs test
Adjust dose in renal insufficency and elderly
Basic Vanc Dosing
15-20 mg/kg given every 8-12 hours
MIC is
Calculating a Pediatric Vancomycin Dose
60 mg/kg/day over 2 years

70 mg/kg/day 3 mo-2 years
Monitoring Vancomycin with Trough Levels
30 minutes prior to next does

Steady state just before 4th dose
Optimal Trough Concentrations
Staphylococcus aureus maintain troughs >10 mcg/ml to avoid development recistanece

15-20 trough for complicated infections
Vanc related toxicities
Uriticarial or erythematous reaction
Tachycardia
Hypotension

Stop infuion
Administer antihistomine
Discontinue or slow infusion
Nephrotoxicity
Variable incidience in literature
Usually reversible
Increased Risk
-Concurrent nephrotoxic drugs
-Larger doses
-Higher trough (over 15)
Lonber course (over 7 days)
-Pre-existing renal insufficiency
-Intensive care unit
Treatment of Recurrent Skin Abcess
Search for local couse (pilonidal cyst, hidradenitis, suppurativa, foreign material)

Drain and culture the abcess

Treat with know effective antibiotic for 5-10 days

Consider decolonsization
-Intranazal mupirocin BID 5 days
-Chlorhexidine washes
-Daily washin of sheets, towels, clothes

Evaluate for neutrophil disorders if recurrent infecionts began in early childhood
Animal Bit wounds
Prevention of SSTIs coused by dog or cat bites
Give 3-5 days antibiotic
-Immunocompromised
-Aspenia
-Advanced Liver disease
-Edema
-Moderate or worse injury, especily hands or face
-Injuries that penetrated the periosteum or joint capsule
-Injuries that penetreated the priosteum or joint capsule

RABIES

AUGMENTIN for bite infection
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