1. BY: MARINA IBRAHIM PHARM-D CANDIDATE FAMU COLLEGE OF PHARMACY AND PHARMACEUTICAL SCIENCES SOFT SKIN INFECTIONS (CELLULITIS)

2. OBJECTIVES Prevalence Etiology Pathophysiology Definition Risk Factors Signs and symptoms Diagnosis Treatment Non-Pharmacological Pharmacological Pharmacist role

3. PREVALENCE Cellulitis is not a reportable disease, the prevalence is unknown. However, it is a relatively common infection, affecting all racial and ethnic groups. Studies found a higher incidence of cellulitis in individuals >45 years old.

4. ETIOLOGY Cellulitis may be caused by indigenous flora colonizing the skin and appendages. Major organisms involved: Staphylococcus Aureus (S. Aureus) Streptococcus Pyogenes (S. Pyogenes) Bacteria enters the body in many ways: Breaks in the skin Burns Insect bites Surgical incisions Intravenous (IV) catheters

5. ETIOLOGY (CONT…) A more serious staphylococcus infection may lead to methicillin-resistant Staphylococcus aureus (MRSA).

6. PATHOPHYSIOLOGY Pathophysiology: Bacteria that enters the body through a cut or other wound. Wound that becomes untreated causes many different organisms to grow. Which, leads to different types of Soft Skin Infections.

7. CELLULITIS Definition: Cellulitis is a common bacterial skin infection. Appears as a swollen, red area of skin that feels hot and tender, and it may spread rapidly. If left un-treated may affect tissues underlying the skin and can spread into the lymph nodes and bloodstream. Other type: Erysipelas: superficial Cellulitis: deeper (subcutaneous).

8. ERYSIPELAS (CELLULITIS) Microorganisms: Group A streptococcus (S. Pyogenes) Signs and Symptoms: Blisters Fever, shaking, and chills Painful, very red, swollen, and warm skin underneath the lesion. Skin lesion with a raised border Sores on the cheeks and bridge of the nose Diagnosis: Diagnosed based on how the skin looks.

9. RISK FACTORS Risk Factors: Known injury Weakened immune system Skin conditions (eczema, athlete's foot, chickenpox and shingles) that cause breaks in the skin and increase your risk of cellulitis. Chronic swelling of your arms or legs (lymphedema) History of cellulitis Intravenous drug use Obesity

10. SIGNS AND SYMPTOMS Signs and Symptoms: Redness Swelling Tenderness Pain Warmth Fever

11. DIAGNOSIS Diagnosis: Blood tests Wound culture Other tests to help rule out a DVT (Ultrasound, MRI or CT scan, venography, blood tests.)

12. TREATMENT Out Patient: (7-10 day treatment) Cellulitis: Dicloxacillin (Dynapen) 125mg (mild) or 250-500mg (moderate to severe) orally four times daily Clindamycin (Cleocin HCL) 150-300mg three or four times daily orally Amoxicillin/Clavulanate (Augmentin) 500mg three times daily or 875mg twice daily orally.

13. TREATMENT Outpatient: First Generation Cephalosporins Cefadroxil (Duricef) 1g orally once daily or divided BID Cefazolin (Ancef) Mild: 250-500mg IV/IM q8hrs Moderate-Severe: 0.5-1g IV/IM Q6-8hrs Severe, Life threatening: 1-1.5g IV/IM Q6-8hrs Cephalexin (Keflex) 500mg orally BID

14. TREATMENT Outpatient cont…: MRSA (community-acquired): consider if cellulitis is associated with pus. Sulfamethoxazole/Trimethoprim (Bactrim) 1-2 tablets DS orally twice daily. May need to combine with cephalexin or penicillin. β-lactam allergy: Azithromycin (Zithromax) 500mg orally for one day Then 250mg orally daily for four days Clarithromycin (Biaxin) 250mg orally BID for 7-10 days. Clindamycin (Cleocin) 150-300mg orally Q6hrs 300-450mg orally Q6hrs for more severe infections MRSA-associated: 300-450mg orally 3 times daily for 5-10 days. 600mg orally 3 times daily for complicated skin and soft tissue infections (7-14 days duration)

15. TREATMENT Hospitalized patients Streptococci and S. aureus (MRSA-acquired): Clindamycin (Cleocin) 600mg IV Q8hrs Vancomycin 15mg/kg IV Q12hrs Linezolid (Zyvox) 600mg IV Q12hrs Daptomycin (Cubicin) 4mg/kg IV Q24hrs Ceftaroline (Rocephin) 600mg IV Q12hrs Telavancin (Vibativ) 10 mg/kg IV once daily (infuse over 1 hr)

16. TREATMENT Hospitalized Patients cont…: Beta-lactamase inhibitors combinations: Augmentin (Amoxicillin/Clavulanate) Mild to moderate: 500mg orally BID or 250mg orally Q8hrs. Severe: 875mg orally Q12hrs or 500mg orally Q8hrs. Unasyn (Ampicillin/Sulbactam) 1.5g-3g IV/IM Q6hrs (Maximum dose: 4g) Zosyn (Piperacillin/Tazobactam) 3.375g IV Q6hrs for 7-10 days Timentin (Clavulanate/Ticarcillin) >60kg: Mild-Moderate infection: 3.1 IV Q6h Severe: 3.1g IV Q4hrs <60kg: Mild-Moderate infection: 200mg/kg/day IV Q6hrs Severe: 300mg/kg/day IV divided Q4hrs.

17. TREATMENT Treatment (5-10 days): Antistaphylococcal Penicillin Nafcillin (Nafcil) 500mg IV/IM Q4-6hrs Oxacillin (Bactocill) Mild to moderate: 250-500mg IV/IM Q4-6hrs Severe: 1g IM/IV Q4-6hrs.

18. TREATMENT CONT… Penicillin V (staphylococcal) 250-500mg orally Q6-8hrs.

19. NON-PHARMACOLOGICAL TREATMENT Cool sterile saline dressings initially to reduce pain. Warm, moist heat to aid in localization and allow spontaneous drainage. Elevation and immobilization may reduce the edema and swelling. Topical dressings provide a protective barrier against infective organism.

20. PHARMACIST ROLE Wash wound daily with soap and water. Apply an antibiotic cream or ointment on surface wounds. Watch for signs of infection. Redness, pain and drainage all are signs of possible infection. People with diabetes and those with poor circulation need to take extra precautions to prevent skin wounds and treat any cuts or cracks in the skin promptly. Inspect your feet daily Moisturize your skin regularly. Lubricating your skin helps prevent cracking and peeling. Protect your hands and feet. Wear appropriate footwear and gloves. Promptly treat any superficial skin infections (athlete's foot). Do NOT wait to treat wounds!

21. QUESTIONS?

22. REFERENCES Dipiro J, Talbert B, Yee GC, Matzke GR, Wells BG, Posey LM (eds.). Pharmacotherapy: A Pathophysiologic Approach, 7th edition, New York, McGraw-Hill, 2008. Micromedex. http:/www.micromedexsolutions.com/micromedex2/libr arian. Accessed October 1, 2013. Gunderson CG, Martinello RA: A systematic review of bacteremias in cellulitis and erysipelas. J Infect Nov 11 Marion, DW. Cellulitis. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013. Mayo Clinic Staff - Mayo Foundation for Medical Education and Research. - July 1 2008 - http://www.mayoclinic.com/health/cellulitis/DS00450