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Keri Holmes-Maybank, MD Medical University of South Carolina September, 2012.

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Presentation on theme: "Keri Holmes-Maybank, MD Medical University of South Carolina September, 2012."— Presentation transcript:

1 Keri Holmes-Maybank, MD Medical University of South Carolina September, 2012

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

6  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  Systemic illness ◦ HR >100 and ◦ Temp >38 o C or <36 o C 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  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  Immune status  Geographic locale  Travel history  Recent trauma or surgery  Previous antimicrobial therapy  Lifestyle - occupation  Hobbies  Animal exposure  Bite exposure

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

11  HR >100, Temp >38 o C and <36 o C, 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  HR >100, Temp >38 o C and <36 o C, Sys<90mmHg  Hypotension and ◦ CRP>13Marked left shift ◦ Elevated creatinineLow serum bicarb ◦ CPK 2 x upper limit of normal  Immune compromise/neutropenia/malignancy  Diabetes  Animal or human bite wounds

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

14  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  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  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  65% relative increase since 1999  600,000 admissions annually

18  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  Saphenous venectomy  Axillary node dissection for breast cancer  Gyn malignancy surgery with lymph node dissection *** in conjuction with XRT  Liposuction

20  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  Deescalation: ◦ Penicillin ◦ Amoxicillin ◦ Amoxicillin/clavulanate ◦ Cephalexin  Treatment duration: ◦ Discontinue abx 3 days after acute inflammation disappears ◦ Usually 5-10 days of treatment

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

23  MRSA coverage  Antibiotics: ◦ Vancomycin ◦ Clindamycin ◦ Linezolid (restricted to ID) ◦ Daptomycin (restricted to ID)

24  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  Elevation of affected leg  Compression stockings  Treat underlying tinea pedis, eczema, trauma  Keep skin well hydrated

26  Acute dermatitis  Gout  Herpes zoster  Lipodermatosclerosis  Deep vein thrombosis  Contact dermatitis  Drug reaction  Foreign body reaction  Herpes zoster

27

28  ALWAYS, ALWAYS ◦ Incision and drainage ◦ Culture aspirate

29  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  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 ◦ Clindamycin ◦ Trimethoprim/sulfamethoxazole + beta lactam ◦ Doxycycline + beta lactam

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

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

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

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

37  Deescalation: ◦ 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

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39  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 <38.5 o C and HR <100 bpm

40  If temperature >38.5 o C 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

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42  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  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 PLUS ◦ Vancomycin ◦ Linezolid (restricted to ID) ◦ Daptomycin (restricted to ID) ◦ (discontinue if culture negative after hours)

44  Deescalation: ◦ Ciprofloxacin and amoxicillin/clavulanate  Treatment duration: ◦ At least 7 days

45  Device predisposes to SSTI  66% Gram positive  Entry site infection ◦ Antibiotics  Tunnel infection and vascular port-pocket infection ◦ Device removal and antibiotics

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47  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  Common, complex, costly  Largest number of diabetes related hospital bed days  Most common proximate, non-traumatic cause of amputations

49  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  Moderate or Severe ulcer ◦ 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  Wound care  Debridement  Glycemic control  Evaluate vascular status

52  Gunderson CG. Cellulitis: Definition, etiology, and clinical features. Am J Med2011;124: 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): 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): Rajan S. Skin and soft-tissue infections: Classifying and treating a spectrum. Cleveland Clinic Journal of Medicine. 2012;79(1):  Swartz MN. Cellulitis. N Engl J Med 2004;350: 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: 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. 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: 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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