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MANAGEMENT OF SKIN AND SOFT TISSUE INFECTIONS Jose A. Vazquez, M.D. Senior Staff Division of Infectious Disease Henry Ford Hospital Professor of Medicine.

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Presentation on theme: "MANAGEMENT OF SKIN AND SOFT TISSUE INFECTIONS Jose A. Vazquez, M.D. Senior Staff Division of Infectious Disease Henry Ford Hospital Professor of Medicine."— Presentation transcript:

1 MANAGEMENT OF SKIN AND SOFT TISSUE INFECTIONS Jose A. Vazquez, M.D. Senior Staff Division of Infectious Disease Henry Ford Hospital Professor of Medicine Wayne State University

2 Skin and Soft Tissue Infections General Considerations n Primary vs. Secondary infections n Portal of entry n Status of host defenses n Associated manifestations u Toxicity, severity of illness n Localization and morphology of lesions n Environmental exposure

3 PRIMARY PYODERMAS u u Impetigo u u Bullous impetigo u u Staphylococcal Scalded Skin Syndrome u u Folliculitis u u Furuncles and Carbuncles u u Erysipelas u u Cellulitis

4 PRIMARY PYODERMAS Impetigo   >90% due to group A Streptococcus u u Most occur in children u u <10% mixture of Staph with Strep u u Manifestations - small vesicles with erythematous halo - pustulates - ruptures - characteristic golden-yellow thick stuck-on crusts - painless - minimal constitutional symptoms



7 PRIMARY PYODERMAS Impetigo Therapy u u Penicillin still drug of choice u u Alternatives: -1st generation cephalosporin (Duricef, Keflex) -If Pen allergic: Erythromycin or Azithromycin u u Local wound care wet-to-dry dressings u u Topical antimicrobials far inferior

8 PRIMARY PYODERMAS Bullous Impetigo u u Primarily in kids u u Due to Staphylococcus group II (Type 71) u u Manifestations: - Begin as vesicles that turn into bullae - Bullae rupture and leave moist red surface - No Nikolsky sign - Finally form a thin “varnish”-like” light brown crust u u Therapy - Dicloxacillin - 1st generation ceph - Erythromycin or Azithromycin

9 PRIMARY PYODERMAS Erysipelas u u A superficial cellulitis of the skin with prominent lymphatic involvement u u Generally due to group A Strep (rarely group C or G) u u Most common in: - infants - young kids - older adults - immunocompromised (diabetics, alcoholic, nephrotic syndrome, venous statsis, paraparesis) u u Portal of entry - skin ulcers, local trauma, abrasions, primary dermatologic conditions, Tineas

10 PRIMARY PYODERMAS Erysipelas - Manifestations u u 70-80% of lesions are on the lower extremity 5-20% are on the fact u u A painful lesion with a bright red edematous indurated appearance and an advancing raised border-sharply demarcated u u Fever u u Bacteremia ~ 5% u u Occasional spread to deeper structures u u Leukocytosis very common

11 PRIMARY PYODERMAS Erysipelas - Manifestations u u Penicillin oral vs parenteral u u Alternatives - 1st generation ceph. - Erythromycin or Azithromycin

12 PRIMARY PYODERMAS Cellulitis u u Acute spreading infection of the skin extending into the subcutaneous tissue u u Etiology: - Staph and Strep most common - Erysipeloid- E. rhusiopathiae - salt water fish, poultry - Anthrax - Bacillus - raw wool - Pseudomonas - spas, heel tennis shoe puncture wounds - Aeromonas - lesions in water - Sporotrichosis - Blastomycosis

13 PRIMARY PYODERMAS Cellulitis u u Generally due to: - Previous trauma - Underlying skin condition u u Skin lesion: borders are not sharply demarcated with erythema, tenderness, warmth, edema u u Fever - malaise - chills u u Regional adenopathy u u Bacteremia ~ 20%

14 PRIMARY PYODERMAS Cellulitis u u If strong suspicion of etiologic agent treat with specific antimicrobial. u u If etiologic agent unknown: - No underlying risk factors 1st generation ceph (cover Staph and Strep) Alternative: if Pen allergic - Erythromycin or Azithromycin (Zithromax)

15 Staphylococcus aureus u Frequent cause of cellulitis, especially in diabetic patients u 2 nd – 3 rd most common cause of BSIs in hospitalized patients. u Etiology: > 80 % line infections: u Susceptibility has evolved dramatically over the past few year


17 What about resistant S. aureus ??

18 Resistance in S. aureus u HA-MRSA u CA-MRSA u VISA or GISA F MIC 8-16 to vancomycin u VRSA F MIC > 32 to vancomycin u HR-SA F MIC < 4 (susceptible) to vancomycin F subpopulations that are VISA Cosgrove SE. et al CID;39:

19 Community-Associated MRSA u Prevalence ~ 36 % u Risk Factors: F Recent hospitalization F Recent antimicrobials F Surgery F Exposure to MRSA colonized person F Athletes (wrestlers, football players) F Chronic illness F Nursing home, jails, IVDU Eguia JM, Chambers HF. Hosp Epidemiol 5:2003

20 Community-Associated MRSA u Most common infections are SSTI and Resp. tract u Many remain susceptible to: clindamycin (89 v 21%); genta (94 v 80%);rifampin (96 v94%); TCN (92%); Bactrim (95v90%) u ~ 60 % probably originate from hospitals or long-term care facilities u Risk Factors: F Recent hospitalization`OR 0-6 months months months months2.2 F Nursing home2.1 Charlebois ED. Et al. CID 2004;39:47-54: Naimi TS. Et al. JAMA;290:

21 Community-Associated MRSA Management u Outpatient F Mild Infection Clindamycin 450mg q8 hrsClindamycin 450mg q8 hrs Doxycycline 100mg BIDDoxycycline 100mg BID Bactrim DS 2 tabs po BIDBactrim DS 2 tabs po BID F Moderate to severe Zyvox 600mg BIDZyvox 600mg BID u Inpatient F Vancomycin 15mg/kg q12 hrs F Zyvox (linezolid) 600mg IV/PO BID F Daptomycin (Cubicin) 4mg/kg Charlebois ED. Et al. CID 2004;39:47-54

22 Management of Gram Positives n MSSA u Nafcillin 2 gm q4 h u Cefazolin (ancef) 2gm q 8 h IV u PCN allergy (vanco or linezolid) IV u Linezolid oral n MRSA u Vancomycin u Linezolid u Daptomycin

23 VRSA – Its All About Sex Michigan Case 1 Michigan Case 1 n Gangrenous foot – VRE, MRSA, multiple courses of vanco n VRE + MRSA = VRSA ( van A ) PA Case 2 n Foot ulcer, VRE in the past. Allergic to Vanco n MRSA 1:132 ( van A)

24 Vancomycin-Resistant Staphylococcus aureus n The isolate was resistant to: – Oxacillin (MIC>16 μ g/mL) – Vancomycin (MIC>128 μ g/mL) n The isolate contained: – The oxacillin resistance gene mecA – The vanA vancomycin resistance gene from enterococci MIC = minimal inhibitory concentration. CDC. MMWR. 2002;51: June 2002: First case of vancomycin-resistant S aureus (VRSA) isolated from a swab obtained from a catheter exit site.

25 SECONDARY PYODERMAS u u Bite wounds u u Infections of burns, wounds, or underlying dematitis u u Diabetic wound infections u u Decubitus ulcers u u Surgical wound infections

26 BITE WOUNDS AND INFECTIONS u u ANIMAL - Dog - Cat - Snake ~ 8,000/year - few get infected - venom is sterile - Exotic animals - monkey tend to be the most serious - organisms will reflect habitat of animals u u HUMAN - Occlusional bites - Clenched-fist injuries

27 CAT BITES Epidemiology u u ~ 400,000/year u u Primarily in women u u Infection rates > 50%/bite - Teeth slender, sharp, closer together - High colony counts - Teeth penetrate into bones, capsules, and bones easier

28 CAT BITES MICROBIOLOGY u u Pasturella multocida isolated > 50% of bites u u Otherwise same isolates as dog u u Rochalimea spp. - R. hensenulae May cause Cat Scratch Disease May produce disseminated disease in immunocompromised host Tx. Erythromycin

29 BITE WOUNDS AND INFECTIONS Dog Bites u u ~ 80% of all animal bites u u ~ 15-20% become infected u u Generally a polymicrobial infection u u Role of prophylactic antimicrobial therapy ??? - No good prospective studies u u Probably prudent to provide antimicrobial coverage for at least 3-5 days after the bite

30 DOG BITES Microbiology u u Gram positive cocci - alpha hemolytic streptococci ~ 30% - S. aureus ~ 15% - S. intermedium ~ 27% - generally in dogs < 40 lbs. - Beta-hemolytic streptococci - Enterococci - Micrococcus

31 DOG BITES Microbiology u u Gram negative rods - Haemophilus - Proteus - E. coli - Enterobacter cloacae

32 DOG BITES Microbiology Pasturella multocida ~ 10-15% Eikinella corrodens Capnocytophagia carimorsus Actinomyces Bacteroides spp. non Fragilis Fusobacterium Peptostreptococci Peptococci Veillonella Eubacterium Rods Anaerobes

33 HUMAN BITES/CLENCHED FIST INJURIES Epidemiology u u Like monkey bites, generally more serious and more prone to develop infection and complications than are animal bites u u Most tend to occur during fights u u ~ 20% of injuries are “love nips” and are related to sexual activity

34 HUMAN BITES/CLENCHED-FIST INJURIES u u Unfortunately most patients tend to wait until the infection has set in before seeking medical attention u u Generally results in cellulitis u u Frequently however, it produces: - deep-space infection - septic arthritis - osteomyelitis u u ~ 20% of injuries require amputation if no antibiotic is provided

35 HUMAN BITES Microbiology u u ~ 55% are mixed polymicrobial infections with anaerobes u u E. corrodens ~ 25% u u S. aureus u u Streptococci u u Hemophilus influenzae

36 BITE WOUND AND INFECTION MANAGEMENT u u Tetanus immunization u u Rabies vaccintion/Rabies immune globulin - if indicated u u Incision/Drainage/Debridement - if indicated u u Gram stain and culture of all material u u Elevation of injured area - frequent cause of failure u u Follow-up - preferably within hours

37 BITE WOUNDS AND INFECTIONS Antimicrobial Therapy - Outpatient u u Amoxicillin-clavulanate (Augmentin) mg TID oral u u Doxycycline 100 mg BID oral u u Tetracycline 500 mg QID oral

38 BITE WOUNDS AND INFECTIONS Antimicrobial Therapy - Inpatient u u Ampicillin-sulbactam (Unasyn) 3.0 gm IVPB Q 6 hrs. u u Cefoxitin or cefotetan 2 gm Q 8-12 hrs. IVPB (No enterococcal coverage) u u Imipenem/cilastin (Primaxin) mg IVPB QID u u Piperacillin/tazobactam (Zosyn) 3.75 gm Q 8 hrs.




42 Building a better mouse trap ?

43 Zyvox (Linezolid) n 1 st oxazolidinone – inhibits protein synthesis at the initiation of 50S ribosome n Spectrum: gram positive pathogens: u Staph aureus (MSSA or MRSA) u Enterococcus F E. fecalis or E. faecium and VRE u Streptococcus Group A u S. pneumonia including (PCN-Resistant SP) u Nocardia spp.

44 Zyvox (Linezolid) n Dose : 600mg BID n Oral and IV n Bioavailability ~ 100% n Metabolism: u ~ 65 % non-renal n AE: diarrhea ~ 8-10 % thrombocytopenia ~ 2.5% thrombocytopenia ~ 2.5%

45 CUBICIN ™ (daptomycin) Overview n Lipopeptide natural product n Activity in Gram-positive organisms only n Bactericidal in vitro and in vivo n Safety profile similar to vancomycin n Long T1/2 (once-daily IV dosing) n No oral formulation n FDA approved for SSTI only.

46 Future Antimicrobial Agents For Gram Positives Organisms n Glycopeptides u Telavancin u Oritavancin u Dalbavancin n Tetracyclines u Tigecycline (broad spectrum activity) n Cephalosporins u Ceftibiprole (5 th generation) F Excellent gram positive activity (MRSA & Enterococcus)

47 Conclusions u Recent data has shown us: u Emerging resistance u CA-MRSA greatest concen ?? u MRSA, GISA, VRSA n Better understanding of mechanisms of antimicrobial resistance - e.g., selective pressure n Better understanding of risk factors predisposing to CA-MRSA infection u Future u Molecular testing for resistance organisms u Newer antimicrobials

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