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Inpatient Skin and Soft Tissue Infections. Keri Holmes- Maybank , MD Medical University of South Carolina. Objectives. Identify appropriate empiric antibiotics for treatment of SSTI’s. Identify appropriate antibiotics for deescalation of SSTI treatment.

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inpatient skin and soft tissue infections

Inpatient Skin and Soft Tissue Infections

Keri Holmes-Maybank, MD

Medical University of South Carolina

objectives
Objectives
  • Identify appropriate empiric antibiotics for treatment of SSTI’s.
  • Identify appropriate antibiotics for deescalation of SSTI treatment.
  • Recognize patients appropriate for inpatient hospitalization of SSTI’s.
  • Recognize appropriate use of blood cultures, needle aspiration and punch biopsies in SSTI’s.
ssti s
SSTI’s
  • Increasing ER visits and hospitalizations
  • 29% increase in admissions, 2000 to 2004
  • Primarily in age <65
  • Presume secondary to community MRSA
  • 50% cellulitis and cutaneous abscesses
  • Estimated $10 billion SSTI 2010
idsa guidelines
IDSA Guidelines
  • “Practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate health care for specific clinical circumstances.”
guidelines
Guidelines
  • Reduce emergence of resistant organisms
  • Reduce hospital days
  • Reduce costs:
    • Blood cultures
    • Consultations
    • Imaging
    • Hospital days
  • 2011-Implementation of treatment guidelines
    • Decreased use of blood cx
    • Decreased advanced imaging
    • Decreased consultations
    • Shorter durations of therapy
    • Decreased use of anti-pseudomonal
    • Decreased use of broader spectrum abx
    • No change in adverse outcomes
    • Decreased costs
inpatient hospitalization
Inpatient Hospitalization
  • Systemic illness
    • HR >100
    • Temp >38oC or <36oC
    • Systolic bp <90 or decrease of 20 mmHg < baseline
  • Hypotension and
    • CRP>13
    • Marked left shift
    • Elevated creatinine
    • Low serum bicarbonate
    • CPK 2 x the upper limit of normal
inpatient hospitalization1
Inpatient Hospitalization
  • Rapid progression of cellulitis
  • Worsening infection despite appropriate antibiotics
  • Tissue necrosis
  • Severe pain
  • Altered mental status
  • Respiratory, renal or hepatic failure
  • Co-morbidities:  immune compromise, neutropenia, asplenia, preexisting edema, cirrhosis, cardiac failure, renal insufficiency
obtain careful history
Obtain Careful History
  • Immune status
  • Geographic locale
  • Travel history
  • Recent trauma or surgery
  • Previous antimicrobial therapy
  • Lifestyle - occupation
  • Hobbies
  • Animal exposure
  • Bite exposure
testing
Testing
  • Blood cultures positive <5%
  • Needle aspiration 5-40%
  • Punch biopsy 20-30%
blood cultures
Blood Cultures
  • HR >100 , Temp >38oC or <36oC, Sys <90mmHg
  • Lymphedema
  • Immune compromise/neutropenia/malignancy
  • Pain out of proportion to exam
  • Infected mouth or eyes
  • Unresponsive to initial antibiotics
  • Splenectomy
  • Diabetes
  • Water-associated cellulitis
  • Recurrent or persistent cellulitis
needle aspiration or skin biopsy
Needle Aspiration or Skin Biopsy
  • HR >100 , Temp >38oC or <36oC, Sys<90mmHg
  • Hypotension and
    • CRP>13 Marked left shift
    • Elevated creatinine Low serum bicarb
    • CPK 2 x upper limit of normal
  • Immune compromise/neutropenia/malignancy
  • Diabetes
  • Animal or human bite wounds
  • Unresponsive to empiric antibiotics
slide12
SSTI
  • Indicators of more severe disease:
    • Low sodium
    • Low bicarb
    • High creatinine
    • New anemia
    • Low or high wbc
    • High CRP (associated with longer hospitalization)
empiric anti mrsa antibiotics
Empiric Anti-MRSA Antibiotics
  • Recent hospitalization
  • Residence in long term care facility
  • Recent antibiotic treatment
  • HIV
  • Men who have sex with men
  • Injection drug use
  • Hemodialysis
  • Incarceration
  • Military service
  • Sharing needles, razors, sports equipment
  • Diabetes
deescalation
Deescalation
  • Acute skin findings resolving
  • Afebrile
  • No signs of systemic illness
  • Should see systemic signs improvement by 48 hours
  • Should see skin improvement 3-5 days by at the latest
broaden antibiotics
Broaden Antibiotics
  • If no improvement in systemic signs in 48 hours
  • If no improvement in skin in 72 hours
  • As antibiotics kill organisms, toxins released may cause a worsening of skin findings in first 48 hours
cellulitis
Cellulitis
  • 65% relative increase since 1999
  • 600,000 admissions annually
risk factors for cellulitis
Risk Factors for Cellulitis
  • Obesity
  • Edema
    • Venous insufficiency
    • Lymphatic obstruction
  • Fissured toe webs
    • Maceration
    • Fungal infection
  • Inflammatory dermatoses – eczema
  • Repeated cellulitis
  • Subcutaneous injection or illegal drugs
  • Previous cutaneous damage
  • All lead to breaches in the skin for organism invasion
surgical risk factors
Surgical Risk Factors
  • Saphenousvenectomy
  • Axillary node dissection for breast cancer
  • Gyn malignancy surgery with lymph node dissection *** in conjuction with XRT
  • Liposuction
non purulent cellulitis
Non-Purulent Cellulitis
  • No purulent drainage, no exudate, no associated abscess
  • beta hemolytic streptococci
  • Antibiotics:
    • Nafcillin
    • Cefazolin
    • Ceftriaxone
    • Clindamycin
    • Vancomycin
  • Modify to MRSA coverage if
    • No improvement in skin findings within 72 hours
    • Signs of severe systemic illness
non purulent cellulitis1
Non-Purulent Cellulitis
  • Deescalation:
    •  Penicillin
    • Amoxicillin
    • Amoxicillin/clavulanate
    • Cephalexin
  • Treatment duration:
    • Discontinue abx 3 days after acute inflammation disappears
    • Usually 5-10 days of treatment
purulent complicated cellulitis
Purulent/Complicated Cellulitis
  • Purulent drainage
  • Exudate
  • Absence of a drainable abscess
  • Deeper tissue - surgical/traumatic wound infection, major abscess, infected ulcer or burn
purulent complicated cellulitis1
Purulent/Complicated Cellulitis
  • MRSA coverage
  • Antibiotics:
    • Vancomycin
    • Clindamycin
    • Linezolid (restricted to ID)
    • Daptomycin (restricted to ID)
purulent complicated cellulitis2
Purulent/Complicated Cellulitis
  • Deescalation:
    • Clindamycin
    • Trimethoprim/sulfamethoxazole
    • Linezolid (restricted to ID)
  • Treatment duration:
    • Discontinue abx 3 days after acute inflammation disappears
    • Usually 5-10 days of treatment
secondary treatment of cellulitis
Secondary Treatment of Cellulitis
  • Elevation of affected leg
  • Compression stockings
  • Treat underlying tineapedis, eczema, trauma
  • Keep skin well hydrated
confused with cellulitis
Confused with Cellulitis
  • Acute dermatitis
  • Gout
  • Herpes zoster
  • Lipodermatosclerosis
abscess1
Abscess
  • ALWAYS, ALWAYS
    • Incision and drainage
    • Culture aspirate
abscess when to add antibiotics
Abscess –When to Add Antibiotics
  • Multiple sites of infection
  • Rapid progression in presence of cellulitis
  • Systemic illness (fever, hypotension, tachycardia)
  • Immune compromise
  • Elderly
  • Difficult to drain area (hand, face, genitalia)
  • Lack of response to incision and drainage
  • Septic phlebitis - multiple lesions
  • Gangrene
abscess antibiotic coverage
Abscess Antibiotic Coverage
  • MRSA coverage:cellulitis, severe disease, rapid progression, septic phlebitis, constitutional symptoms, difficult to drain
  • Antibiotics:
    • Vancomycin
    • Clindamycin
    • Daptomycin (restricted to ID)
    • Linezolid (restricted to ID)
  • c-MRSA or beta hemolytic streptococci
  • Antibiotics
    • Clindamycin
    • Trimethoprim/sulfamethoxazole + beta lactam
    • Doxycycline + beta lactam
abscess2
Abscess
  • Deescalation:
    • Clindamycin
    • Trimethoprim/sulfamethoxazole
    • Linezolid (restricted to ID)
  • Treatment duration:
    • Discontinue abx 3 days after acute inflammation disappears
    • Usually 5-10 days of treatment
animal bites1
Animal Bites
  • Pasteurella – mc organism
  • Antibiotics:
    • Ampicillin/sulbactam
    • Piperacillin/tazobactan
    • Cefoxitin
    • Meropenem
    • Ertapenem (restricted to ID and Surgery)
  • Tetanus toxoid (if not up to date)
animal bites2
Animal Bites
  • Deescalation
    • Amoxicillin/clavulanate
    • Doxycycline
  • Treatment duration:
    • Discontinue abx 3 days after acute inflammation disappears
    • Usually 5-10 days of treatment
human bite
Human Bite
  • Antibiotics:
    • Ampicillin/sulbactam
    • Meropenem
    • Ertapenem (restricted to ID and Surgery)
  • Tetanus toxoid (if not up to date)
  • Closed fist***
  • Antibiotics:
    • Cefoxitin
    • Ampicillin/sulbactam
    • Ertapenem(restricted to ID and Surgery)
  • Tetanus toxoid (if not up to date)
  • Hand surgery consult***
human bites1
Human Bites
  • Deescalation:
    • Amoxicillin/clavulanate
    • Moxifloxacin + clindamycin
    • Trimethoprim/sulfamethoxazole + metronidazole
  • Treatment duration:
    • Discontinue abx 3 days after acute inflammation disappears
    • Usually 5-10 days of treatment if no joint or tendon involvement
surgical site infection1
Surgical Site Infection
  • Pain, swelling, erythema, purulent drainage
  • Usually have no clinical manifestations for at least 5 days after operation
  • Most resolve without antibiotics
  • Open all incisions that appear infected >48 hours after surgery
  • No antibiotics if temperature <38.5oC and HR <100 bpm
surgical site infection2
Surgical Site Infection
  • If temperature >38.5oC or HR >100 bpm:
  • Trunk, head, neck, extremity
    • Cefazolin
    • Clindamycin
    • Vancomycin if MRSA is suspected
  • Perineum, gi tract, female gu tract
    • Cefotetan
    • Ampicillin/sulbactam
    • Ceftriaxone + metronidazole or clindamycin
    • Fluoroquinolone + clindamycin
  • Treatment duration:
    • Usually 24-48 hours or for 3 days after acute inflammation resolves
neutropenic patients with ssti
Neutropenic Patients with SSTI
  • ALWAYS blood CULTURES
  • Initial infection - <7 days neutropenia
  • Antibiotics
    • Carbapenems
    • Cefepime
    • Ceftazidine
    • Piperacillin/tazobactam

PLUS

    • Vancomycin
    • Linezolid (restricted to ID)
    • Daptomycin (restricted to ID)
    • (discontinue if culture negative after 72-96 hours)  
neutropenic patients with ssti1
Neutropenic Patients with SSTI
  • Subsequent infection- >7days neutropenia (fungi, viruses, atypical bacteria)
  • Treatment:
    • Amphotericin B
    • Micafungin (may require higher dose and ID consult)
    • Voriconazole (restricted to ID, Heme/Onc, Critical Care, Pulmonary, and Transplant)

PLUS

    • Carbapenems
    • Cefepime
    • Ceftazidine
    • Piperacillin/tazobactam

PLUS

    • Vancomycin
    • Linezolid (restricted to ID)
    • Daptomycin (restricted to ID)
    • (discontinue if culture negative after 72-96 hours)
neutropenic patients with ssti2
Neutropenic Patients with SSTI
  • Deescalation:
    • Ciprofloxacin and amoxicillin/clavulanate
  • Treatment duration:
    • At least 7 days
vascular access devices in neutropenia
Vascular-Access Devices in Neutropenia
  • Device predisposes to SSTI
  • 66% Gram positive
  • Entry site infection
    • Antibiotics
  • Tunnel infection and vascular port-pocket infection
    • Device removal and antibiotics
diabetic foot ulcers1
Diabetic Foot Ulcers
  • Common, complex, costly
  • Largest number of diabetes related hospital bed days
  • Most common proximate, non-traumatic cause of amputations
diabetic foot ulcers2
Diabetic Foot Ulcers
  • Always obtain specimen (biopsy, ulcer curettage, aspiration) and treat with antibiotics and wound care
  • Mild ulcer
    • Cellulitis or erythema extends <2cm around ulcer, infection limited to skin
  • Antibiotics:
    • Clindamycin
    • Cephalexin
    • Amoxicillin/clavulanate
    • Trimethoprim/sulfamethoxazole
  • Treatment duration
    • Usually 1-2 weeks treatment
diabetic foot ulcers3
Diabetic Foot Ulcers
  • Moderate or Severe ulcer
    • Cellulitis or erythema extends >2cm around ulcer, fever, ams, hypotension, leukocytosis, acidosis, severe hyperglycemia
  • Antibiotics:
    • Vancomycin and ceftazidime
    • (consider adding metronidazole, piperacillin/tazobactam, meropenem)
  • Deescalation:
    • Moxifloxacin
    • Amoxicillin/clavulanate
    • Trimethoprim/sulfamethoxazole
  • Treatment duration:
    • Usually 2-4 weeks of treatment
secondary treatment of diabetic foot ulcers
Secondary Treatment of Diabetic Foot Ulcers
  • Wound care
  • Glycemic control
  • Evaluate vascular status
references
References
  • Gunderson CG. Cellulitis: Definition, etiology, and clinical features. Am J Med2011;124:1113-1122. 
  • Jenkins TC, et al. Decreased antibiotic utilization after implementation of a guideline for inpatient cellulitis and cutaneous abscess.  Arch Intern Med. 2011;171(12):1072-1079.
  • Rajan S. Skin and soft-tissue infections: Classifying and treating a spectrum. Cleveland Clinic Journal of Medicine. 2012;79(1):57-66. 
  • Swartz MN. Cellulitis. N Engl J Med 2004;350:904-912.
  • IDSA GUIDELINES:
  • Lipsky BA, et al. Diagnosis and treatment of foot infections. Clin Infect Dis  2004;39:885-910.
  • Liu C, et al. Clinical practice guidelines by the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011;52(3):e18-e55.
  • Stevens DL, et al. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis  2005;41:1373-1406.