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Inpatient Skin and Soft Tissue Infections

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Presentation on theme: "Inpatient Skin and Soft Tissue Infections"— Presentation transcript:

1 Inpatient Skin and Soft Tissue Infections
Keri Holmes-Maybank, MD Medical University of South Carolina September, 2012

2 Objectives Identify appropriate empiric antibiotics for treatment of SSTI’s. Identify appropriate antibiotics for deescalation of SSTI treatment. Recognize patients appropriate for inpatient hospitalization of SSTI’s. Recognize appropriate use of blood cultures, needle aspiration and punch biopsies in SSTI’s.

3 Key Messages Blood culture for skin and soft tissue infections are extremely low yield, approximately 5%. Consider hospitalization for patients with systemic signs of illness. MRSA infections have led to an increase in skin and soft tissue infections. Using guidelines for skin and soft tissue infections leads to a decrease in the emergence of antibiotic resistance.

4 SSTI’s Increasing ER visits and hospitalizations
29% increase in admissions, 2000 to 2004 Primarily in age <65 Presume secondary to community MRSA 50% cellulitis and cutaneous abscesses Estimated $10 billion SSTI 2010

5 IDSA Guidelines “Practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate health care for specific clinical circumstances.”

6 Guidelines Reduce emergence of resistant organisms
Reduce hospital days Reduce costs: Blood cultures Consultations Imaging Hospital days 2011-Implementation of treatment guidelines Decreased use of blood cx Decreased advanced imaging Decreased consultations Shorter durations of therapy Decreased use of anti-pseudomonal Decreased use of broader spectrum abx No change in adverse outcomes Decreased costs

7 Inpatient Hospitalization
Systemic illness HR >100 and Temp >38oC or <36oC and Systolic bp <90 or decrease of 20 mmHg < baseline Hypotension and CRP>13 Marked left shift Elevated creatinine Low serum bicarbonate CPK 2 x the upper limit of normal

8 Inpatient Hospitalization
Rapid progression of cellulitis Worsening infection despite appropriate antibiotics Tissue necrosis Severe pain Altered mental status Respiratory, renal or hepatic failure Co-morbidities:  immune compromise, neutropenia, asplenia, preexisting edema, cirrhosis, cardiac failure, renal insufficiency

9 Obtain Careful History
Immune status Geographic locale Travel history Recent trauma or surgery Previous antimicrobial therapy Lifestyle - occupation Hobbies Animal exposure Bite exposure

10 Testing Blood cultures positive <5% Needle aspiration 5-40%
Punch biopsy 20-30%

11 Blood Cultures HR >100 , Temp >38oC and <36oC, Sys <90mmHg
Lymphedema Immune compromise/neutropenia/malignancy Pain out of proportion to exam Infected mouth or eyes Unresponsive to initial antibiotics Water-associated cellulitis Diabetes Recurrent or persistent cellulitis Concern for a cluster or outbreak

12 Needle Aspiration or Skin Biopsy
HR >100 , Temp >38oC and <36oC, Sys<90mmHg Hypotension and CRP>13 Marked left shift Elevated creatinine Low serum bicarb CPK 2 x upper limit of normal Immune compromise/neutropenia/malignancy Diabetes Animal or human bite wounds

13 SSTI Indicators of more severe disease: Low sodium Low bicarb
High creatinine New anemia Low or high wbc High CRP (associated with longer hospitalization)

14 Empiric Anti-MRSA Antibiotics
Recent hospitalization Residence in long term care facility Recent antibiotic treatment HIV Men who have sex with men Injection drug use Hemodialysis Incarceration Military service Sharing needles, razors, sports equipment Diabetes

15 Deescalation Acute skin findings resolving Afebrile
No signs of systemic illness Should see systemic signs improvement by 48 hours Should see skin improvement 3-5 days by at the latest

16 Broaden Antibiotics If no improvement in systemic signs in 48 hours
If no improvement in skin in 72 hours As antibiotics kill organisms, toxins released may cause a worsening of skin findings in first 48 hours

17 Cellulitis 65% relative increase since 1999
600,000 admissions annually

18 Risk Factors for Cellulitis
Obesity Edema Venous insufficiency Lymphatic obstruction Fissured toe webs Maceration Fungal infection Inflammatory dermatoses – eczema Repeated cellulitis Subcutaneous injection or illegal drugs Previous cutaneous damage All lead to breaches in the skin for organism invasion

19 Surgical Risk Factors Saphenous venectomy
Axillary node dissection for breast cancer Gyn malignancy surgery with lymph node dissection *** in conjuction with XRT Liposuction

20 Non-Purulent Cellulitis
No purulent drainage, no exudate, no associated abscess beta hemolytic streptococci Antibiotics: Nafcillin Cefazolin Ceftriaxone  Clindamycin Vancomycin Modify to MRSA coverage if No improvement in skin findings within 72 hours Signs of severe systemic illness

21 Non-Purulent Cellulitis
Deescalation:  Penicillin Amoxicillin Amoxicillin/clavulanate Cephalexin Treatment duration: Discontinue abx 3 days after acute inflammation disappears Usually 5-10 days of treatment

22 Purulent/Complicated Cellulitis
Purulent drainage Exudate Absence of a drainable abscess Deeper tissue - surgical/traumatic wound infection, major abscess, infected ulcer or burn

23 Purulent/Complicated Cellulitis
MRSA coverage Antibiotics: Vancomycin Clindamycin Linezolid (restricted to ID) Daptomycin (restricted to ID)

24 Purulent/Complicated Cellulitis
Deescalation: Clindamycin Trimethoprim/sulfamethoxazole Linezolid (restricted to ID) Treatment duration: Discontinue abx 3 days after acute inflammation disappears Usually 5-10 days of treatment

25 Secondary Treatment of Cellulitis
Elevation of affected leg Compression stockings Treat underlying tinea pedis, eczema, trauma Keep skin well hydrated

26 Confused with Cellulitis
Acute dermatitis Gout Herpes zoster Lipodermatosclerosis Deep vein thrombosis Contact dermatitis Drug reaction Foreign body reaction

27 Abscess

28 Abscess ALWAYS, ALWAYS Incision and drainage Culture aspirate

29 Abscess –When to Add Antibiotics
Multiple sites of infection Rapid progression in presence of cellulitis Systemic illness (fever, hypotension, tachycardia) Immune compromise Elderly Difficult to drain area (hand, face, genitalia) Lack of response to incision and drainage Septic phlebitis - multiple lesions Gangrene

30 Abscess Antibiotic Coverage
MRSA coverage:cellulitis, severe disease, rapid progression, septic phlebitis, constitutional symptoms, difficult to drain Antibiotics: Vancomycin Clindamycin Daptomycin (restricted to ID) Linezolid (restricted to ID) c-MRSA or beta hemolytic streptococci Antibiotics Trimethoprim/sulfamethoxazole + beta lactam Doxycycline + beta lactam

31 Abscess Deescalation: Treatment duration: Clindamycin
Trimethoprim/sulfamethoxazole Linezolid (restricted to ID) Treatment duration: Discontinue abx 3 days after acute inflammation disappears Usually 5-10 days of treatment

32 Animal Bites

33 Animal Bites Pasteurella – mc organism Antibiotics:
Ampicillin/sulbactam Piperacillin/tazobactan Cefoxitin Meropenem Ertapenem (restricted to ID and Surgery) Tetanus toxoid (if not up to date)

34 Animal Bites Deescalation Treatment duration: Amoxicillin/clavulanate
Doxycycline Treatment duration: Discontinue abx 3 days after acute inflammation disappears Usually 5-10 days of treatment

35 Human Bites

36 Human Bite Antibiotics: Tetanus toxoid (if not up to date)
Ampicillin/sulbactam Meropenem Ertapenem (restricted to ID and Surgery) Tetanus toxoid (if not up to date) Closed fist*** Cefoxitin Ertapenem(restricted to ID and Surgery) Hand surgery consult***

37 Human Bites Deescalation: Treatment duration: Amoxicillin/clavulanate
Moxifloxacin + clindamycin Trimethoprim/sulfamethoxazole + metronidazole  Treatment duration: Discontinue abx 3 days after acute inflammation disappears Usually 5-10 days of treatment if no joint or tendon involvement

38 Surgical Site Infection

39 Surgical Site Infection
Pain, swelling, erythema, purulent drainage Usually have no clinical manifestations for at least 5 days after operation Most resolve without antibiotics Open all incisions that appear infected >48 hours after surgery No antibiotics if temperature <38.5oC and HR <100 bpm

40 Surgical Site Infection
If temperature >38.5oC or HR >100 bpm: Trunk, head, neck, extremity Cefazolin Clindamycin Vancomycin if MRSA is suspected Perineum, gi tract, female gu tract Cefotetan Ampicillin/sulbactam Ceftriaxone + metronidazole or clindamycin Fluoroquinolone + clindamycin Treatment duration: Usually hours or for 3 days after acute inflammation resolves

41 Neutropenia and SSTI’s

42 Neutropenic Patients with SSTI
ALWAYS blood CULTURES Initial infection - <7 days neutropenia Antibiotics Carbapenems Cefepime Ceftazidine Piperacillin/tazobactam PLUS Vancomycin Linezolid (restricted to ID) Daptomycin (restricted to ID) (discontinue if culture negative after hours)  

43 Neutropenic Patients with SSTI
Subsequent infection- >7days neutropenia (fungi, viruses, atypical bacteria) Treatment: Amphotericin B Micafungin (may require higher dose and ID consult) Voriconazole (restricted to ID, Heme/Onc, Critical Care, Pulmonary, and Transplant) PLUS Carbapenems Cefepime Ceftazidine Piperacillin/tazobactam Vancomycin Linezolid (restricted to ID) Daptomycin (restricted to ID) (discontinue if culture negative after hours)

44 Neutropenic Patients with SSTI
Deescalation: Ciprofloxacin and amoxicillin/clavulanate Treatment duration: At least 7 days

45 Vascular-Access Devices in Neutropenia
Device predisposes to SSTI 66% Gram positive Entry site infection Antibiotics Tunnel infection and vascular port-pocket infection Device removal and antibiotics

46 Diabetic Foot Ulcers

47 Infected Diabetic Foot Ulcers
Not all diabetic foot ulcers are infected. Indications of infection: Purulent secretions OR 2 of manifestations of inflammation: Redness Warmth Swelling/induration Pain/tenderness

48 Diabetic Foot Ulcers Common, complex, costly
Largest number of diabetes related hospital bed days Most common proximate, non-traumatic cause of amputations

49 Diabetic Foot Ulcers Always obtain specimen (biopsy, ulcer curettage, aspiration) and treat with antibiotics and wound care Mild ulcer Cellulitis or erythema extends <2cm around ulcer, infection limited to skin Antibiotics: Clindamycin Cephalexin Amoxicillin/clavulanate Trimethoprim/sulfamethoxazole Treatment duration Usually 1-2 weeks treatment

50 Diabetic Foot Ulcers Moderate or Severe ulcer Antibiotics:
Cellulitis or erythema extends >2cm around ulcer, fever, ams, hypotension, leukocytosis, acidosis, severe hyperglycemia Antibiotics: Vancomycin and ceftazidime (consider adding metronidazole, piperacillin/tazobactam, meropenem) Deescalation: Moxifloxacin Amoxicillin/clavulanate Trimethoprim/sulfamethoxazole Treatment duration: Usually 2-4 weeks of treatment

51 Secondary Treatment of Diabetic Foot Ulcers
Wound care Debridement Glycemic control Evaluate vascular status

52 References Gunderson CG. Cellulitis: Definition, etiology, and clinical features. Am J Med2011;124:   Jenkins TC, et al. Decreased antibiotic utilization after implementation of a guideline for inpatient cellulitis and cutaneous abscess.  Arch Intern Med. 2011;171(12): Rajan S. Skin and soft-tissue infections: Classifying and treating a spectrum. Cleveland Clinic Journal of Medicine. 2012;79(1):57-66.  Swartz MN. Cellulitis. N Engl J Med 2004;350:   IDSA GUIDELINES: Lipsky BA, et al. Diagnosis and treatment of foot infections. Clin Infect Dis  2004;39: Liu C, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011;52(3):e18- e55. Stevens DL, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis  2005;41:

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