Skin and Soft Tissue Emergencies Dennis Djogovic MD, FRCPC

Financial Disclosures  None to declare

Objectives  When should skin infections be of special concern?  Differential?  Treatment priorities?

Case 1  23 previously healthy male presents to the ED with “spider bites” to his left lower leg  Clinically stable vitals and appearance  Medical Hx: benign  Social Hx: lives at home. Competitive wrestler

 Non systemic cellulitis  PO Abx  Evidence based choices are poor  Retrospective analyses

 O/E:  Chest/abd exam normal  Lower left leg  Normal pulses, sensation, strength  small pustules (<1mm in size), mild surrounding redness, non painful

 Make sure you cover for Strep and Staph  Staph  Do you need to worry about MSSA or MRSA?

PO Abx Choices  Keflex  Strep and MSSA  Clinda  Strep, MSSA, MRSA  Amoxicillin  Strep  But not staph  Septra, Doxycycline  Staph (MSSA and MRSA)  But not strep  Linezolid

MRSA background  Methicillin (B lactamase) in use since 1959  Outbreaks of MRSA since the 1960s  Hospital acquired  Far more virulent  Community acquired  Less virulent (usually)  Community prevalence increasing

MRSA per Ward, MSSA (N=818); MRSA (N=295) CAN-WARD Incidence of MRSA in Different Settings WARD TYPE % OF ALL S. aureus ICU15.7% Surgical Ward9.2% Medical Ward27.8% ER24.2% Outpatient Clinic23.1% Overall26.5%

MRSA tips  Age <2  First nations  Close proximity to many people  Athletes  Prisons  Military  Hospital  Skin breaks  IVDU  Skin disorders  Known colonizers

Case 2  23 previously healthy male presents to the ED with “spider bites” to his left lower leg  Treated with clindamycin, swab grew MRSA  5 days later, lesions not healing, and appears to have more cellulitis  Appears clinically unwell  HR 115, 125/70, 38.9C  Erythema of lower leg  Although not rapidly progressive

What is the ideal parenteral therapy?

Vancomycin  Inhibits cell wall synthesis  Fairly safe  Very effective  For now  Greatest level of experience and knowledge  Achieving ideal dose levels not easy  MSSA cleared faster with B lactams than Vanc  Tissue penetration variable  Bone, CSF

Linezolid  Bacteriostatic  Inhibits at ribosomal level  Excellent tissue bioavailability  IV or PO

Linezolid  Adverse effects  Thrombocytopenia  Anemia  Lactic acidosis  Above mostly in the prolonged use setting  Serotonin syndrome  Reversibly binds MOA, if added to serotonin agent

Vanco vs Linezolid  Linezolid versus vancomycin for the treatment of methicillin-resistant Staphylococcus aureus infections. Stevens DL, Herr D, Lampiris H, Hunt JL, Batts DH, Hafkin. Clin Infect Dis. 2002;34(11):1481  hospitalized adults with known or suspected methicillin-resistant Staphylococcus aureus (MRSA) infections  linezolid (600 mg twice daily; n=240) or vancomycin (1 g twice daily; n=220) for 7-28 days.  S. aureus was isolated from 53% of patients; 93% of these isolates were MRSA. Skin and soft-tissue infection was the most common diagnosis,  days after the end of therapy, no statistical difference between the 2 treatment groups  clinical cure rates (73.2% of linezolid group and 73.1% in vancomycin group)  microbiological success rates (58.9% linezolid group, 63.2% vancomycin group)  similar rates of adverse event

Case 3  62 yr old female presents with triage complaint of “blisters”  Groan…

Case 3  62 yr old female  2 day duration  Now also in her mouth  Rapidly worsening  HR 120, BP 105/50, 38.4C, RR 26/min

Blisters- Bad or just gross?  Acuity?  Sick?  Localized or widespread?  Mucus membranes?  Patient  Sick?  Immunocompromised?  Age?  New meds?  Blisters: tough or fragile?

Mucous Membranes?  HSV  SJS/TENS  Pemphigus vulgaris  Pemphigus paraneoplastic  Mucus membrane pemhigoid  type of Bullous Pemphigoid

Stevens-Johnson Syndrome/ Toxic Epidermal Necrolysis Syndrome (SJS/TENS)  An acute, immunologically mediated desquamation disorder secondary to infectious or environmental exposure.  Very uncommon. (1/500000)  BUT it can lead to disastrous sequelae akin to a major burn.  Mortality SJS – 10%  Mortality TENS – 30%

Risk Factors  Any viral infection prior to triggering exposure, notably HIV+  Medication exposures  Active malignancy  Southeast Asian Ethnicity

Early Prognostic Markers  Age >40  Active Malignancy  Tachycardia (>120) at presentation  % TBSA desquamated  Serum Bicarbonate <20mmol/L at presentation  Uremia at presentation (>10mmol/L)  Hyperglycemia at presentation (>14mmol/L)

SCORTEN Prognostic Score SCORTEN ScoreMortality % % % % 5 or more90%

Management  Prompt identification and withdrawal of trigger.  General principles of burn care.  Appropriate fluid resuscitation  Wound care/Debridement  Steroids**  IVIG**  Mucosal / Ophthalmological involvement require appropriate specialist involvement.

UAH Burn Unit-Suspected Trigger Cefazolin2 Diltazem1 TMP-SMX3 Phenytoin1 Vancomycin1 Atorvastatin2 Lamogtridine1 Allopurinol1 Mycoplasma pneumonia1 - **Viral serology was sought on all patients with a diagnosis of SJS/TENS and was all non-contributory.

Observations on Triggers  The average time from onset of rash to stopping of medication was 10 days (range 2-30)

Case 4  86 yr old male  Dementia  2 week onset of blisters on arms, legs (creases)  A few have popped/leaked over past day

Bullous Pemphigoid versus Pemphigous Vulgaris  PemphigoiD = Deep  VulgariS = Superficial  OR  Vulgaris = vulgar = ugly = sick and bad!

 Refer early  Not many acute therapies in the ED  Maybe IV steroids?  Make sure you are not missing infection!!  If on a recent abx, use a different class (TENS?!)

Case 5  Healthy 32 yr female  Gardening yesterday, scratched left arm on fence  Nightime fever  Awoke with painful red rash on left arm  Spreading  HR 130, BP 90/50, O2 sat 91%  VBG: 40/26/7.18/lactate 9

Necrotizing skin infections  Necrotizing  Fasciitis  Myositis  Cellulitis  In common  all of these patients are SICK  Only the OR can really tell the difference

Imaging?  Ultrasound  Not too helpful  Can find abscess  MRI  Obtained from the ER??  May overexaggerate soft tissue involvment

Imaging?  Non contrast CT  Looking for air  If you see air, you have necrotizing infection  If you don’t see air, this could still be necrotizing infection  Get your surgeon to look  Ideally in the OR!

Treatment  OR  Antibiotics  Pen G and Clindamycin  +/-IVIG

Take home points  A few ideas on antibiotic choices  Blisters, rashes, lesions  Quick?  Sick?  Tick, tick, tick!!

Thanks for your time! 