Therapeutics Exam 2 : Acute Bacterial Skin and Skin Structure Infections (6), Upper Resipiratory Tract Infections (6), Clotridioides difficle (3), Meningitis (3), Intra-abdominal infections (6), Sexually Transmitted Infections (6) + 2 core calculation

What is the most common etiology for folliculitis?

S. Aureus

What are typical signs & symptoms of folliculitis ?

2-5mm erythematous papules surrounding the hair follicle , central pusulation may be present

What is the typical recommended treatment for folliculitis ?

Typically treated with warm compresses. Can use mupirocin or benzoyl peroxide (if needed)

What is the most common etiology for abscess / furuncle?

S. Aureus

What are typical signs and symptoms of abscess?

Tender, erythematous (reddish), fluctuant nodule not associated with hair follicle

What are the most typical signs and symptoms for furuncle ?

Occurs when folliculitis extends beyond the hair follicle into subcutaneous tissue and leads to a tender , erythematous , fluctuant nodule

What is the typical recommended treatment for abscess / furuncle

Typically treated with warm moist heat. Large lesions require incisions and drainage

What is the most common etiology of carbuncle?

S. Aureus

What are typical signs and symptoms of carbuncle ?

Collection of trundles into a large broad lesions. Systemic signs and symptoms are more common

What is the recommended treatment for carbuncle ?

Typically treated with incision and drainage. If signs are systemic infection treat with dickoxacillin by mouth or 1st gen. Cephalexin by mouth. Can also use bactrim if CA-MRSA suspected

True or False : Antibiotics are not always necessary but should be considered in patients with systemic signs and symptoms for abscess / furuncles / carbuncles

True

What are the RX treatment options for Abscess / furuncles / carbuncles ?

Dicloxacillin 250-500 mg by mouth q6h, or cephalexin 250-500mg by mouth every 6 hours

What are Rx treatment options for CA-MRSA

Bactrim , doxy , clindamycin , vancomycin

What is the most common etiology of impetigo ?

S. Aureus

What are typical signs and symptoms impetigo ?

Thick , yellow or light brown crust on skin due to rupture of fluid filled Bullae. Can cause itching , weakness , fever and diarrhea

What is the recommended treatment for Impetigo?

Typically treated with mupirocin ointment applied topically three times a day for 7 days. For more severe infection or for lesions on the face, use dicloxacillin by mouth or 1st generation cephalosporin (cephalexin) for 7 days

What is the most common etiology of Erysipelas?

Streptococcus pyogenes

What are typical signs and symptoms of erysipelas?

lesion is bright red, edematous (swollen), clearly demaracted raised margins. Fecer and malaise are common.

What is the recommended treatmet for erysipelas?

penicillin VK 250-500mg by mouth every 6 hours for 5 days

What are subjective factors for cellulitis?

1. Chills 2. Malaise 3. Area is painful

What are objective factors for cellulitis?

1. Objective

2. Erthrema and edema of the skin

3. Nonelevated lesion

4. Poorly defined margins

5. Warm to touch

6. Postive cultures

7. Leukocytosis

8. Lymphadenopathy

If there is mild to moderate purulent cellutis or cellulits with access what coverage should be given?

Staphylococcus coverage

If there is severe purulent cellulitis that is empiric coverage for MRSA what should be used?

broad spectrum coverage for patients who are severly immunocomprimised

What are adverse effects of Doxycyline ?

1. Tooth discoloration

2. GI upset and esophagitis

3. Photosensitivity

In what population should you avid giving Doxycycline too?

avoid in children <8 and preganant females

What are counseling points for Doxycyline?

1. Swallowing whole with a full glass of water, while sitting or standing (to avoid esophageal irritation)

2. Taking with food may reduce GI upset and nausea

3. Sepearate administration from oral antiaacids, calcium and iron supplements decrease absorption of doxy (2-3 hours)

What are some adverse side effects of Trimethoprim / Sulfamethoxazole ?

1. Diarrhea

2. Nausea

3. Severe Skin reactions

4. Thrombocytopenia

5. Electrolyte disturbances

What are couseling points for patients that are prescribed of Trimethoprim / SUlfamethoxazole?

1. Taking with food can minimize GI side effects

2. Maintain adequate fluid intake

3. Avoid excessive sunlight

4. Report any rashes or skin reactions, bruising or bleeding asap

What is the duration of therapy for skin infections?

1. at least 5 days is recommended

2. 7-14 days may necessary for hospitalized patients with cellulits

What are goals of therapy?

1. Eradication of the infection - clinical cure

2. Avoidance of mortalily / morbidity

3. Relief of symptoms

4. Avoidance of ADRs

For mild infections for diabetic foot infections what is the most common etiology?

S aureus & streptococcus spp.

What are signs and symptoms of diabetic foot infections?

1. Pain, may be absent due to neuropathy

2. Erythema and edema

3. Pus

4. Delayed healing

5. Increased lesion size

6. Malodor

7. Possible increased WBCs, ESR, CRP, Procalcitonin

how can you prevent foot infection?

1. Wash feet daily in tepid water and dry throroughly

2. Apply lotion to feet to prevent calluses and cracking

3. Ensure that shoes fit properly (not too tight or too loose) and inspect them daily

4. Trim nails regularly, making sure to cut straught across the nail

5. Do not use chemical agents to remove corns or calluses

What factor most favors bacterial growth on the skin?

Excessive moisture

A 4mm erythematous papule with a central pustule surrouding a hair foccicle is most consistent with?

Folliculitis

First-line treament for uncomplicated folliculitis is?

Warm compresses

What differentiates a furuncle from an abscess?

Furuncles originate from a hair follicle

Antibiotics are not always necessary for abscess due to what reason?

Systemic toxicity is uncommon

What infection commonly presents with thick yellow / brown crust after rupture of bullae?

Impetigo

The most common cause of erysipelas is?

Streptococcus pyogenes

A bright red, raised lesion with clearly demarcated margins and fever best describes what?

Erysipelas

What finding is classic for cellulitis?

Poorly defined margins

What is the most common organisms in community-aquired cellulitis?

S. aureus and S. pyogenes

If someone has venous insufficiency what are they at risk for?

Cellulitis

When should MRSA coverage be added for non-severe cellulitis?

If the patient has IV drug use history

What is a non-pharmacologic therapy for cellulitis?

Elevation and immobilization

What is first-line topical treatment for impetigo?

Mupirocin

What is the best monitoring strategy for cellulitis?

Outline the affected area with marker

What are risk factors for Cellulitis?

1. IV drug use

2. Wounds / skin injuries - ulcers, animal bites

3. Venous insufficiency

4. DM

5. Surgery

What are methods of management for cellulitis?

1. Elevation of area

2. Immobilization to decrease swelling

3. Cool sterile saline dressings may decrease pain and can be followed later by moist heat to aid in localization of the cellulitis

4. Incision and drainage (for abscesses / furuncle / carbuncle )

5. Antimicrobial therapy

If a patient has non-purulent cellulitis what is the most causative organism?

Streptococci

If a patient has severe non-purulent cellulits with systemic signs of infections, what should you use?

Broad spectrum coverage including MRSA coverage

For oupatient what is the typical duration of therapy for skin infections?

At least 5 days is recommended

How many days may be necessary for hospitalizated patients with cellulitis?

7 to 14 days

If the patient has a mild foot infection, and has a beta-lactam allergy what should you give them for medication?

1. clindamycin 600mg PO TID

2. Levofloxacin (suboptimal vs. S. aureus

If the patient has mild foot infection, but has had recent antibiotic exposure what should you give them for medication?

1. Amoxicillin - clavulanic acid 875/125

2. ampicillin / sulbactam

3. Levofloxacin or moxifloxacin

If the patient has mild foot infection, but has previous MRSA infection of MRSA colonization, what should you give them for medication?

1. Doxycycline

2. Sulfametoxazole / trimethoprim

If the patient has moderate to severe foot infection, but has been on recent antibiotics what should you give them for medication?

1. Piperacillin-tazobactam

2. Cefuroxime

3. Ceftiaxone

4. Cefotaxime

5. ertapenem

IF the patient has moderate to severe foot infection that has MRSA Risk factors such as HIV infection, admission to nursing homes, or and open wound what should you give them for medication?

1. Vancomycin

2. Linezolid

3. Daptomycin

4. Doxycycline

5. Sulfamethoxazole / trimethoprim