SSTI

What are some risk factors for Skin and Soft Tissue Infections

Abrasion, penetrating wound 

Eczema radiation 

Immunocompromised 

Preexisting infections

Which SSTIs are purulent

Folliculitis

Furuncle

Carbuncle

Abscess

What is Non purulent SSTI

Impetigo

Erysipelas

Cellulitis

necrotizing fascitis

What is Folliculitis

Superficial infection of the hair follicles

What is a Furuncle 

Inflammatory draining nodule involving a hair folcule 

What is a carbuncle

Adjacent duruncles coalscene to form a single area

What is an abscess

Collection of pus within the dermis and deeper skin tissue

How do you manage folliculitis

Resolves spontaneously 

Topical therapy with Mupirocin ointment

How do you manage Furuncle/Carbuncle and Abscess

Incision and Drainage

Administer abx against MRSA in addition to Incision and Drainage

What is the SIRS criteria to determine if the SSTI is severe

Temp is greater than 38 degrees

Tachypnea > 24 breaths per min 

Tachycardia > 90 bpm

WBC greater than 12000

How do you know if there is a purulent Furuncle/Carbuncle/Abscess that is mild

Abcess is greater than 5 cm

How do you empiriclly treat mild SSTI

Incision and Drainage

TMP/SMX

Doxycycline

How do you treat moderate SSTI

Incision and Drainage 

Culture and Sensitivity testing 

What is the empiric treatment of moderate SSRTI

TMP/SMX or Doxycycline

What is the Defined treatment for MRSA moderate SSTI

TMP/SMX

What is the defined treatment for moderate SSTI with MSSA

Dicloxacillin or
Cephalaxin

What is the empiric treatment of severe SSTI

I/D

C/S

Vancomycin, Dapto, Linezolid, Telvancin, Ceftaroline

What do you give for severe MSSA infection

Nafcillin or Cefazolin or Clindamycin

What adjunctive abx should be given for Mild purulent SSTI

Doxy or TMP/SMX

What is the treatment duration

7-14 days

Case 1: A 25-year-old female presents with a 7cm abscess of her right axilla. She has no systemic signs of infection and NKDA. Which of the following would be the most appropriate treatment recommendation for her?

Incision and drainage plus trimethoprim/sulfamethoxazole

After I&D, pus was sent for culture.
The patient starts complaining of a rash that she noticed since starting TMP/SMX. Based on this new information, which is the best therapy?

Change to doxycycline

Which infections are nonpurulent

Impetigo

Eysipelas

Cellulitis

necrotizing faciitis

What is Nonbollous Impetigo

Most common caused by Beta Hemolytic strep/staph a

Small fluid filled vesicles, pustules, ruptures

What is Bullous Impetigo

Caused by S.aureus

There are vessicles with clear yellow fluid

How do you treat mild Impetigo

Topical Mupirocin BID x 5 days

How do you treat impetigo with multiple lesions involving the face

PO antibiotics against MSSA x 7 days 

Dicloxacillin

Cephalaxin 

What do you use if MRSA suspected in Impetigo

Doxycycline

TMP/SMX

What is Erysipelas

Cellulitis involving more superficial layers and associated with group A strep

How do you treat mild-mod Erysipelas

Penicillin VK 250-500mg 

How do you treat severe Eysipelas

Pen G 1-2 mil units IV

What is cellulitis

Infects epidermis and dermis

Spreads to superficial fascia caused by group A strep and staph

What are nonpharmacological measures to manage cellulitis

Elevate and immobilize area to decrease swelling 

cold dressings 

surgical intervention 

How do you treat purulent Cellulitis outpatient

TMP/SMX PO

Doxycycline

How do you treat nonpurulent Moderate cellulitis

PO beta lactams: Penicillin VK, cephlaxin, dicloxacillin

How do you treat purulent cellulitis Hospitalized 

Vancomycin 

Daptomycin 

Ceftaroline

Telavancin

How do you treat non purulent cellulitis hospitalized

Cefazolin and Ceftrixone

Vancomycin

Vancomycin + Piperacillin tazobactam

What is Type 1 Necrotizing Fascitis

Polymicrobial Infection

After trauma or surgery

What is type 2 Necrotizing fascitis

Monomicrobial infection 

What is type 3 Necrotizing Fascitis

Gas gangrene

Advances rapidly over a few hours

What do all Nerotizing fascitis patient need

Surgical debridement

What empiric treatment is given for Nec Fasc

Piperacillin/Tazo + Vancomycin 

What drugs are given for Nec Fasc definitive antibiotics

Penicillin + Clindamycin

How long should abx treatment go on for Nec Fasc

Debridment no longer needed

Afebrile 48-72 hours

Case 2: JA, 31-year-old female, presents to the ED with complaints of an extremely painful case of cellulitis without sharply demarcated regions. She has a temperature of 101 and WBC of 15,000. The ED physician is worried about necrotizing
fasciitis and calls an emergent surgery consult. What empiric
antibiotics should be initiated for JA assuming she has no
known drug allergies?

Vancomycin + piperacillin-tazobactam

What is Osteomyelitis

Inflammation of the bone marrow and surrounding bone

What are the causes of Osteomyelitis

Hematogenous Spread-spread to the bone through bloodstream

Contigous Spread- direct infection from adjacent tissues

Which bacteria causes OSteomyelitis

S Aureus

How do you diagnose Osteomyelitis

Probe to bone

X rays

MRI

Bone biposy

How do manage Osteomyelitis

Surgical intervention

Antibiotics

Which antibiotic is given for MSSA Osteomyelitis

Nafcillin 

Oxacillin 

Cefazikin

What Abx given for MRSA OSteomyelitis

Vanco

Daptomycin

Linezolid

Which abx given for gram neg including pseudomonas

Ciprofloxacin

Levo

Ceftazidime

Cefepime

Which abx is given for anerobes 

Metronidazole

§AJ, a 46-year-old man, has been diagnosed with osteomyelitis on the 5^th digit of his left foot. He is refusing amputation and would like to try antibiotics to cure his infection. A wound culture is showing MSSA. Which of the following is the most appropriate in the management of AJ’s osteo?

a)Start Nafcillin and monitor weekly CPR/ESR

§MJ, a 68-year-old man, presents with a foul-smelling diabetic foot infection on his right heel. In the ED, his wound was positive for probe to bone and an MRI confirmed osteomyelitis on his left heel. He received surgical debridement and bone cultures were sent from the OR. Which of the following empiric antimicrobial therapy is most appropriately for MJ at this time?

a.Vancomycin + piperacillin-tazobactam

§MJ started empirically on vancomycin and piperacillin-tazobactam. His bone cultures reveal MRSA . He has no known allergies and other active medications include insulin, sertraline, and enalapril. Which of the following antibiotic therapy is most appropriate for MJ based on his culture results?

a)Discontinue piperacillin-tazobactam and continue vancomycin