George Smulian MD 2318 Question 1 A 22 yo M is seen in clinic for a painful spot on his right leg It appeared approximately 3 days ago Of note he is on the football team at the local university On exam he is afebrile with normal heart rate and blood pressure He has no streaking or ID: 775457
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Slide1
Skin and Joint Infections
George Smulian, MD
2/3/18
Slide2Question 1
A 22 y/o M is seen in clinic for a painful spot on his right leg. It appeared approximately 3 days ago. Of note, he is on the football team at the local university. On exam he is afebrile with normal heart rate and blood pressure. He has no streaking or lymphadenopathy. A 3 cm x 3 cm tender, fluctuant lesion is palpable over his right thigh. No erythema is noted. In addition to incision and drainage, what else needs to be done?
Oral CephalexinOral DoxycyclineOral CiprofloxacinIV VancomycinClose clinical follow up
Slide3Skin and Soft Tissue Infections
Represent a spectrum of diseaseCellulitisPurulent SSTINecrotizing infectionsSeverity classificationsMildModerate: systemic signsSevere: failed prior tx, SIRS, immunocompromised
Slide4Slide5Skin and Soft Tissue Infections
Risk factors
Damaged skin and diminished local host defenses
Obesity
Prior trauma
Prior cellulitis
Edema (venous or lymphatic)
Slide6Non-Purulent Cellulitis
Typically streptococcal species; MRSA is an uncommon causeDouble-blind RCT of Cephalexin +/- SMX/TMP: no difference1Don’t biopsy or culture unless super sick or unusual circumstances (immunocompromised, animal bite, immersion)5 days of therapy is as good as 10 days if improving!2Antibiotics for non-purulent cellulitis (treat Streptococcus)Oral agents: Penicillins, Cephalosporins, ClindamycinIV agents: Cefazolin, Ceftriaxone, Pip/Tazo, Clindamycin
Pallin
et al.
CID
. 2013; 56:1754-62
Hepburn et al.
Arch
Int
Med
. 2004; 164:1669-74
Slide7Purulent SSTIs
Incision and drainage is standardUsually Staphylococcus aureus (think MRSA)For abscess <5cm, likely don’t need antibiotics1,2Administer systemic antibiotics if:Impaired host defensesSigns of systemic infectionMultiple abscessesFailure of I&DPurulent (treat MRSA)Oral agents: SMX/TMP, Doxycycline, Clindamycin, LinezolidIV agents: Vancomycin, Daptomycin, Ceftaroline
Schmitz et al.
Ann
Emerg
Med
. 2010; 56:283-7
Lee at al.
Pediatr
Infect Dis J
. 2004; 23:123-7
Slide8Necrotizing Fasciitis
Infection of the deeper tissues, muscle fascia and subcutaneous fatProgresses along fascia due to its poor blood supply Muscles frequently spared as very vascularOverlying tissue can appear normal or red, swollen, warm, shiny and extremely tenderRapid progression with overlying skin color change, bullae formation, frank gangreneSwelling can cause compartment syndrome and myonecrosis
Slide9Necrotizing Fasciitis
Risk factorsDiabetesPVDImmunocompromisedRecent surgeryMicrobiologyGroup A Strept (GAS)Mixed anaerobe/aerobeStaph aureus, Vibrio vulnificus, Aeromonas hydrophila
Management
Source control via surgical debridement
Broad spectrum
abx
MRSA coverage (
Vanc
,
Dapto
, Linezolid)
PLUS
Beta-lactam/beta-lactamase inhibitor (Pip/
Tazo
) or
Carbapenem
PLUS
Clindamycin
Tailor to cultures, PCN plus
Clinda
for GAS
Slide10Question 2
A 55 y/o F with a history of psoriatic arthritis on Infliximab presents to your clinic for a dog bite to her left hand that occurred 4 hours prior. The dog is up to date on its vaccinations. She last received a tetanus vaccination 2 yrs ago. Her vital signs are normal and her physical exam is significant only for several small punctures and abrasions of the left hand with minimal surrounding erythema. She has only mild discomfort in the area. X-ray shows no fracture, foreign body or gas. What further intervention needs to be performed?
Prescribe a 3-5 day course of Amoxicillin/ClavulanateAdmission for intravenous Ampicillin/SulbactamRepeat tetanus vaccinationConsult a hand surgeon for debridement of the affected areaNo further evaluation or therapy
Slide11Dog/Cat Bites
Pre-emptive antimicrobial therapy (3-5 days)ImmunocompromisedAsplenicAdvanced liver diseaseEdema of the affected areaModerate to severe injuryPenetrated periosteum or joint capsuleHands, face, genitaliaUpdate tetanus toxoid vaccine
Once infected, often
polymicrobial
Staph, Strep,
Pasteurella
(cats>dogs),
Capnocytophagia
, anaerobes
Humans add
Eikenella
, anaerobic GNR’s
Amoxicillin/
Clavulanate
is always right!
If PCN allergic, consider
Moxi
, Doxy, SMX/TMP plus Metro
Slide12Diabetic Foot Infections
Frequent co-existing immune deficiency, neuropathy,
vasculopathy
Risk factors:
Persistent ulcer >1 month
Peripheral arterial disease
Prior amputation
Recurrent ulcers
Post-traumatic foot wound
CKD
Walking barefoot
Probe to bone
Slide13Diabetic Foot Infections
Consider infected if at least 2 of the following:
Purulent discharge
Warmth
Pain/tenderness
Swelling/Induration
Erythema
Slide14Diabetic Foot Infections
Classify severity
Mild
No deeper than skin and subcutaneous tissues
AND
Erythema <2 cm beyond ulcer
Moderate
Extends to deeper tissue
OR
Erythema >2 cm beyond ulcer
AND
Does not meet SIRS criteria
Severe
SIRS
Evidence of systemic infection
Critical ischemia
Slide15Lipsky
et al.
CID
. 2012; 54:132-173
Slide16Diabetic Foot Infections
Do:
Assess for arterial insufficiency
Wound care (cleansing, debridement, pressure off loading)
Image all new infections
Cover severe infections with broad spectrum antibiotics (including
PsA
and MRSA coverage)
Don’t:
Take superficial swabs
Slide17Question 3
A 24 y/o F patient who is a known intravenous drug user is seen in the hospital for acute onset of left knee pain. She is febrile to 101ºF and tachycardic to 110. An arthrocentesis is performed. Joint fluid analysis shows 100,000 WBCs, of which 90% are neutrophils. Fluid is sent for culture. The Gram stain is shown below. In addition to surgical intervention, which of the following is the most appropriate empiric antimicrobial therapy?
Intravenous CefazolinIntravenous VancomycinIntravenous Vancomycin and CeftriaxoneIntravenous Vancomycin and CefepimeOral Doxycycline
Slide18Infectious Arthritis
Risk factorsAge >80 yearsDiabetes mellitusRheumatoid arthritisProsthetic jointRecent joint surgery/injectionSkin infectionIntravenous drug abuseLocationKnee, then hip
Pathogenesis
Hematogenous
spread (~70%)
Bite or trauma
Inoculation during surgery
Microbiology
Staph aureus
Other GPC’s (
Strept
)
Neisseria gonorrhea
Slide19Infectious Arthritis
Usually monoarticularJoint painSwelling (effusion)Warmth Restricted/painful movementFever/chillsIf polyarticular think…Underlying rheum diseaseEndocarditisGonococcus
Synovial fluid analysis
>50K WBC, mostly PMNs
Gram stain positive ~40%
Synovial culture
Gram stain with
GPCs: Vancomycin
GNRs: 3
rd
gen Cephalosporin
Negative: Vancomycin (add 3
rd
gen Cephalosporin if immunocompromised)
Slide20Question 4
63 y/o M with history of diabetes presents to your clinic for evaluation of a rash. Patient states that approximately 2 days ago he began having pain in his right shoulder. 24 hrs later he noted a red bumpy rash. He has no other complaints. The rash is shown below. What is the best course of action?
Observation onlyValacyclovir for 7 days and pain control with NSAIDsValacyclovir for 7 days and a steroid dose packValacyclovir for 7 days and pain control with GabapentinHospitalization for intravenous Acyclovir
Slide21Herpes Zoster
Reactivation of the virus that caused chickenpox75% have prodromal pain at site of subsequent eruptionPainful, unilateral erythematous papular -> vesicular eruptionTypically restricted to a dermatomal distributionNo longer infectious once crusted over (~7-10 days)
Slide22Herpes Zoster
ComplicationsPost-herpetic neuralgia10-15%, mostly >60 years oldHerpes zoster ophthalmicusReactivation in trigeminal ganglionAcute retinal necrosisHerpes zoster oticusRamsay Hunt syndromeIpsilateral facial paralysis, ear pain, and vesicles in the auditory canal and auricle Bacterial super-infection
Slide23Herpes Zoster
TreatmentOral antivirals (Acyclovir, Valacyclovir, Famciclovir)Symptoms <72hrs or new lesions still arisingPain management (no role for steroids in uncomplicated)May need IV agents if neurologic complicationsPrevention: Shingrix/ZostavaxGrade 1B if ≥60 (50% RRR)Grade 2B if ≥50Not Zostervax if pregnant or immunocompromised
Treatment benefits
Lessen the severity and duration of pain associated with acute neuritis
Faster healing of skin lesions
Prevent new lesions
Reduce the risk of transmission
Prevent PHN?
Slide24Questions?