Skin and Soft Tissue Infections

SKIN AND SOFTTISSUE INFECTIONS

EVIDENCE-BASED MANAGEMENT

NATHAN CLEVELAND, MD, MS UNIVERSITY MEDICAL CENTER 22 AUGUST 2012

EVIDENCE-BASED MANAGMENT

SKIN AND SOFT TISSUE INFECTIONS

“Criton, in Thasus, while still on foot, and going about, was seized with a violent pain in the great toe; he took to bed the same day, had rigors and nausea, recovered his heat slightly, at night was delirious. On the second, swelling of the whole foot, and about the ankle erythema, with distension and small bullae (phlyctaenae); acute fever; he became furiously deranged; alvine discharges bilious, unmixed, and rather frequent. He died on the second day from the commencement.”

HIPPOCRATES, 4th Century B.C.

VISUAL I.D.

SSTI OVERVIEW

GOALS

INTRO

HISTORY

TITLE

NOT GOALS

ANATOMY



HISTORY

“Thou art a boil, a plague-sore,an embossed carbuncle, in my

corrupted blood.”

-King Lear, Act II, Scene IV

VISUAL I.D.

SSTI OVERVIEW

GOALS

INTRO

HISTORY

TITLE

NOT GOALS

ANATOMY



“Most recommendations for the diagnosis and treatment of skin and soft-tissue infections are based on tradition, consensus, or (too often) medical mythology. The literature on this subject is crippled by a paucity of randomized, controlled trials.”

THE SSTI PROBLEM

FAQs

Slaven EM, DeBlieux PM. Skin and soft tissue infections: The common, the rare and the deadly. EM Practice 2001;3(1):1-22

VISUAL I.D.

SSTI OVERVIEW

GOALS

INTRO

HISTORY

TITLE

NOT GOALS

ANATOMY



GOALS

CELLULITIS1. Review skin anatomy2. Describe types of SSTIs3. Current best evidence• Diagnosis• Management

4. Highlight CDC and IDSA recommendations

FAQs

VISUAL I.D.

SSTI OVERVIEW

GOALS

INTRO

HISTORY

NOT GOALS

ANATOMY



NOT GOALS

vs ERYSIPELAS1.

2.

3.

4.

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

GOALS

INTRO

NOT GOALS

ANATOMY



NOT GOALS

5. vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

GOALS

INTRO

NOT GOALS

ANATOMY



ANATOMY

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

GOALS

NOT GOALS

ANATOMY



1. Bacterial, fungal, viral, parasitic

2. Focus on bacterial

3. Classified based on depth

4. Many names – SSTI, cSSSI, ABSSSI

SSTI OVERVIEW

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

NOT GOALS

ANATOMY



CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



Infectious epidermal eruptions of flaccid pustules, which rupture to form a thick honey-colored to brown crust.

IMPETIGO

CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



Inflammation of the hair follicle that appears clinically as an eruption of

pustules and/or papules centered upon hair follicles.

FOLLICULITIS

CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



An ulcerative pyoderma of the skin often referred to as a deeper form of

impetigo.

ECTHYMA

CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



Acute beta-hemolytic group A streptococcal infection of the skin involving the superficial

dermal lymphatics that causes marked swelling.

ERYSIPELAS

CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



Deep subcutaneous infection of the skin that results in a localized area of

erythema and inflammation.

CELLULITIS

CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



All that is red is not cellulitis!

CELLULITIS?

CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



Localized infection with accumulation of PMN leukocytes with tissue necrosis

involving the dermis and subcutaneous tissue.

ABSCESS

CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



An infection of the deeper layers of skin and subcutaneous tissues which spreads along

fascial planes. Type I = polymicrobial infection, Type II = monomicrobial infection.

NECROTIZING FASCIITIS

CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW

ANATOMY



THE QUESTIONS

CELLULITIS: Q2

CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.

SSTI OVERVIEW



CELLULITIS AND ERYSIPELAS

BLOOD Cx

CELLULITIS: Q2

CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS

FAQs

VISUAL I.D.



• Dermal and subdermal

• Ill-defined• Indolent• Less systemic

symptoms

CELLULITIS vs ERYSIPELAS

CELLULITIS: Q3

• Dermal lymphatics

• Well-demarcated• Acute onset• More systemic

symptoms

BLOOD Cx

CELLULITIS: Q2

CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELASCELLULITIS

FAQs



CELLULITIS RISK FX

IMAGING

IMMUNOCOMPROMISE LYMPHEDEMA VASCULARINSUFFICIENCY

OBESITY TINEA /INTERTRIGO

CELLULITIS: Q3

BLOOD Cx

CELLULITIS: Q2

CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS

CELLULITIS



CELLULITIS QUESTION 1:

Should I try to culture or biopsy cellulitis?

CELLULITIS: Q4

IMAGING

CELLULITIS: Q3

BLOOD Cx

CELLULITIS: Q2

CULTURE

CELLULITIS: Q1

RISK FX

vs ERYSIPELAS



1. Few studies, none recent2. Vary widely in success

CELLULITIS

ORGANISMS

QUESTION 1: Should I try to

culture or biopsy cellulitis?

CELLULITIS: Q4

IMAGING

CELLULITIS: Q3

BLOOD Cx

CELLULITIS: Q2

CULTURE

CELLULITIS: Q1

RISK FX



1. Few studies, none recent2. Vary widely in success

CELLULITISQUESTION 1: Should I try to


ORGANISMS

CELLULITIS: Q4

IMAGING

CELLULITIS: Q3

BLOOD Cx

CELLULITIS: Q2

CULTURE

CELLULITIS: Q1

RISK FX



1. Few studies, none recent2. Vary widely in success3. Not cost effective, rarely

changes management

CELLULITISQUESTION 1: Should I try to


ORGANISMS

CELLULITIS: Q4a

IMAGING

CELLULITIS: Q3

BLOOD Cx

CELLULITIS: Q2

CULTURE

CELLULITIS: Q1

RISK FX




What about blood cultures?

CELLULITIS: Q4b

ORGANISMS

CELLULITIS: Q4a

IMAGING

CELLULITIS: Q3

BLOOD Cx

CELLULITIS: Q2

CULTURE

CELLULITIS: Q1



CELLULITIS

MRSA

QUESTION 2: What about

blood cultures?

• Meta-analysis: 5 studies, 844 pts

• Mostly inpatients

CELLULITIS: Q4b

ORGANISMS

CELLULITIS: Q4a

IMAGING

CELLULITIS: Q3

BLOOD Cx

CELLULITIS: Q2

CULTURE



CELLULITISQUESTION 2: What about

blood cultures?

• Largest study: Perl B, et al. Cost-effectiveness of blood cultures for adult patients with cellulitis. Clin Infect Dis. 1999;29: 1483-1488

• 2% positive Cx, 82% gram+

MRSA

CELLULITIS: Q4b

ORGANISMS

CELLULITIS: Q4a

IMAGING

CELLULITIS: Q3

BLOOD Cx

CELLULITIS: Q2

CULTURE



CELLULITISQUESTION 2: What about

blood cultures?

MRSA

CELLULITIS: Q4b

ORGANISMS

CELLULITIS: Q4a

IMAGING

CELLULITIS: Q3

BLOOD Cx

CELLULITIS: Q2

CULTURE




Do I need to image cellulitis?

CELLULITIS: Q5

MRSA

CELLULITIS: Q4b

ORGANISMS

CELLULITIS: Q4a

IMAGING

CELLULITIS: Q3

BLOOD Cx

CELLULITIS: Q2



• Often “soft” findings on XR, US, CT

• No studies on imaging cellulitis

• XR reasonable for foreign body

CELLULITIS

ANTIBIOTICS

QUESTION 3: Do I need to image

cellulitis?

Struk DW. Munk PL. Lee MJ. Ho SG. Worsley DF. Imaging of soft tissue infections. Radiologic Clinics of North America. 2001;39(2):277-303

CELLULITIS: Q5

MRSA

CELLULITIS: Q4b

ORGANISMS

CELLULITIS: Q4a

IMAGING

CELLULITIS: Q3

BLOOD Cx




Which organisms commonly cause

cellulitis / erysipelas?(i.e. do I have to cover MRSA?)

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA

CELLULITIS: Q4b

ORGANISMS

CELLULITIS: Q4a

IMAGING

CELLULITIS: Q3



ERYSIPELAS

IDSA RECS

QUESTION 4: Which

organisms cause cellulitis?

Erysipelas = strep

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA

CELLULITIS: Q4b

ORGANISMS

CELLULITIS: Q4a

IMAGING



CELLULITISQUESTION 4: Which


• Short answer:• We can’t culture• No one biopsies• We don’t really know

IDSA RECS

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA

CELLULITIS: Q4b

ORGANISMS

CELLULITIS: Q4a

IMAGING





• 66% isolates = strep

IDSA RECS

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA

CELLULITIS: Q4b

ORGANISMS

CELLULITIS: Q4a

IMAGING





• 50% isolates = staph• 27% isolates = strep• 27% isolates = “other”

Chira S, Miller LG. Staphylococcus aureus is the most common identified cause of cellulitis: a systematic review.Epidemiol Infect. 2010;138(3):313-7.

IDSA RECS

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA

CELLULITIS: Q4b

ORGANISMS

CELLULITIS: Q4a

IMAGING





• Diabetes changes microbiology• 56% gram+ cocci• 22% gram- aerobes• 22% gram- anaerobes

IDSA RECS

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA

CELLULITIS: Q4b

ORGANISMS

CELLULITIS: Q4a

IMAGING



CELLULITIS QUESTION 4b:

Do I have to cover MRSA?

ABSCESS

IDSA RECS

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA

CELLULITIS: Q4b

ORGANISMS

CELLULITIS: Q4a



• CA-MRSA is most common cause of “purulent” cellulitis in the ED

CELLULITIS

ABSCESS: Q1

QUESTION 4b: Do I have to cover MRSA?

ABSCESS

IDSA RECS

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA

CELLULITIS: Q4b

ORGANISMS



• Assume CA-MRSA causes “non-purulent” cellulitis sometimes

• But... Probably not as common

CELLULITISQUESTION 4b: Do I have to cover MRSA?

ABSCESS: Q1

ABSCESS

IDSA RECS

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA

CELLULITIS: Q4b

ORGANISMS




So then, what antibiotic should I use

in cellulitis?

ABSCESS I&D

ABSCESS: Q1

ABSCESS

IDSA RECS

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA

CELLULITIS: Q4b



CELLULITIS

ABSCESS: Q2

QUESTION 5: So then, what

antibiotic for cellulitis?

ABSCESS I&D

ABSCESS: Q1

ABSCESS

IDSA RECS

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA



CELLULITISQUESTION 5: So then, what


Moran GJ, Krishnadasan A, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355(7):666-74

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1

ABSCESS

IDSA RECS

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA



CELLULITIS: ABX RECSQUESTION 5: So then, what


Frazee BW, Lynn J, et al. High prevalence of methicillin-resistant Staphylococcus aureus in emergency department skin and soft tissue infections. Ann Emerg Med.

2005;45(3):311-20

1. MRSA should be covered (first line) only in certain high-risk populations

HomelessJail

IVDURecent hospitalization /

Abx

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1

ABSCESS

IDSA RECS

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA



CELLULITIS: ABX RECSQUESTION 5: So then, what


Phillips S, et al. Analysis of empiric antimicrobial strategies for cellulitis in the era of methicillin-resistant Staphylococcus aureus. Ann Pharmacother. 2007

Jan;41(1):13-20

2. The safest, most cost-effective strategy depends on local prevalence

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1

ABSCESS

IDSA RECS

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5

MRSA



CELLULITIS: CDC RECS

PACKING



http://www.cdc.gov/mrsa/mrsa_initiative/skin_infection/mrsa_algorithm.html

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1

ABSCESS

IDSA RECS

CDC RECS

ANTIBIOTICS

CELLULITIS: Q5




CELLULITIS: IDSA RECS

ABSCESS: Q3



Stevens DL, Bisno AL, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections.

Clin Infect Dis. 2005;41(10):1373-406

PACKING

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1

ABSCESS

IDSA RECS

CDC RECS

ANTIBIOTICS







Clin Infect Dis. 2005;41(10):1373-406

Outpt 1st Line (A-I): • Semisynthetic PCNs - dicloxacillin• 1st / 2nd gen cephalosporin - cephalexin

Outpt 2nd Line (or PCN allergy) (A-I):• Macrolide – erythro/azithromycin• Clindamycin• Fouroquinolones – levofloxacin

MRSA coverage only if suspected

ABSCESS: Q3

PACKING

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1

ABSCESS

IDSA RECS

CDC RECS

ANTIBIOTICS







Clin Infect Dis. 2005;41(10):1373-406

Outpt 1st Line (A-I): • Semisynthetic PCNs - dicloxacillin• 1st / 2nd gen cephalosporin - cephalexin

Outpt 2nd Line (or PCN allergy) (A-I):• Macrolide – erythro/azithromycin• Clindamycin• Fouroquinolones – levofloxacin

MRSA coverage only if suspected

ABSCESS: Q3

PACKING

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1

ABSCESS

IDSA RECS

CDC RECS

ANTIBIOTICS







Clin Infect Dis. 2005;41(10):1373-406

Inpt 1st Line (A-I):• Pen G, nafcillin, oxacillin, cefazolin

Inpt (PCN allergy) (A-I):• Clindamycin, vancomycin, tigecycline,

linezolid

ABSCESS: Q3

PACKING

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1

ABSCESS

IDSA RECS

CDC RECS

ANTIBIOTICS



ABSCESSIMAGING

ABSCESS: Q3

PACKING

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1

ABSCESS

IDSA RECS

CDC RECS



ABSCESS QUESTION 1:How/why should I

I&D abscesses?

ABSCESS: Q4

IMAGING

ABSCESS: Q3

PACKING

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1

ABSCESS

IDSA RECS



ABSCESS

ANESTHESIA

QUESTION 1: How / why

should I I&D abscesses?

Macfie J, Harvey J. The treatment of acute superficial abscesses: a prospective clinical trial. Br J Surg 1977; 64:264–6.

Tonkin DM, Murphy E, et al. Perianal abscess: a pilot study comparing packing with nonpacking of the abscess cavity. Dis Colon Rectum. 2004 Sep;47(9):1510-4.

Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med 1985; 14:15–9.

• I&D alone is effective in most cases

ABSCESS: Q4

IMAGING

ABSCESS: Q3

PACKING

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1

ABSCESS



ABSCESSQUESTION 1: How / why


Macfie J, Harvey J. The treatment of acute superficial abscesses: a prospective clinical trial. Br J Surg 1977; 64:264–6.

• I&D alone is effective in most cases

• 1⁰ closure increases recurrence

ANESTHESIA

ABSCESS: Q4

IMAGING

ABSCESS: Q3

PACKING

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1

ABSCESS



ABSCESSQUESTION 1: How / why


Abraham N, Doudle M, Carson P. Open versus closed surgical treatment of abscesses: a controlled clinical trial. Aust N Z J Surg. 1997 Apr;67(4):173-6.

• Some studies of closure after I&D

• These do not apply to us!!

ANESTHESIA

ABSCESS: Q4

IMAGING

ABSCESS: Q3

PACKING

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1

ABSCESS



ABSCESS QUESTION 2:Do I need to pack all

abscesses?

ABSCESS: Q5

ANESTHESIA

ABSCESS: Q4

IMAGING

ABSCESS: Q3

PACKING

ABSCESS: Q2

ABSCESS I&D

ABSCESS: Q1



ABSCESS

MRSA

QUESTION 2: Do Do I need to

pack all abscesses?

Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med 1985; 14:15–9.

• Probably not

• Wick or soak instead

ABSCESS: Q5

ANESTHESIA

ABSCESS: Q4

IMAGING

ABSCESS: Q3

PACKING

ABSCESS: Q2

ABSCESS I&D



ABSCESS QUESTION 3:Should I image

abscesses?

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA

ABSCESS: Q4

IMAGING

ABSCESS: Q3

PACKING

ABSCESS: Q2



ABSCESS

ANTIBIOTICS

QUESTION 2: Should I image

abscesses?Ultrasound is probably useful in SSTI:• Squire et al (2005) – Bedside US 86%

sensitive and 70% specific for abscess• Tayal et al (2006) – Bedside US

changed management in about half

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA

ABSCESS: Q4

IMAGING

ABSCESS: Q3

PACKING



ABSCESSQUESTION 2: Should I image

abscesses?

Plain film should be ordered for FB

CT if concern that cavity tracks deep

Struk DW. Munk PL. Lee MJ. Ho SG. Worsley DF. Imaging of soft tissue infections. Radiologic Clinics of North America. 2001;39(2):277-303.

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA

ABSCESS: Q4

IMAGING

ABSCESS: Q3

PACKING



ABSCESS QUESTION 4:What is the best way

to anesthetize abscesses?

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA

ABSCESS: Q4

IMAGING

ABSCESS: Q3



ABSCESS

IDSA

QUESTION 4: What is the best

way to anesthetize? Local anesthesia rarely sufficient

• Incision → loculations → express → pack

Halvorson GD, Halvorson JE, Iserson KV. Abscess incision and drainage in the emergency department--Part I. J Emerg Med. 1985;3(3):227-32

.

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA

ABSCESS: Q4

IMAGING



ABSCESSQUESTION 4: What is the best

way to anesthetize? Local anesthesia rarely sufficient

• Incision → loculations → express → pack

Combo anesthesia works best• Ring block outside erythema, then

inject roof• Regional blocks when available• Systemic analgesia• Sometimes conscious sedation

Halvorson GD, Halvorson JE, Iserson KV. Abscess incision and drainage in the emergency department--Part I. J Emerg Med. 1985;3(3):227-32

.

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA

ABSCESS: Q4

IMAGING



ABSCESS QUESTION 5:What percentage of

abscesses are MRSA+?

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA

ABSCESS: Q4



MRSA ABSCESS

NEC FASC: Q1

QUESTION 4: What

percentage are MRSA+? MRSA carries additional virulence

genes (Panton-Valentine leukocidin)

Davis SL, Perri MB, et al. Epidemiology and outcomes of community-associated methicillin-resistant Staphylococcus aureus infection. J Clin Microbiol.

2007;45(6):1705

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA



MRSA ABSCESSQUESTION 4: What


genes (Panton-Valentine leukocidin)• USA 300 – not from hospitals

Kazakova SV, Hageman JC, et al. A Clone of Methicillin-Resistant Staphylococcus aureus among Professional Football Players. N Engl J Med 2005;352:468.

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA





genes (Panton-Valentine leukocidin)• USA 300 – not from hospitals• Inducible clindamycin resistance

Deresinski S. Methicillin-Resistant Staphylococcus aureus: An Evolutionary, Epidemiologic, and Therapeutic Odyssey. Clinical Infectious Diseases

2005;40:562–573.

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA





genes (Panton-Valentine leukocidin)• USA 300 – not from hospitals• Inducible clindamycin resistance• Recurrent in 10-23%

Daum RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med. 2007;357(4):380-90

.

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA





genes (Panton-Valentine leukocidin)• USA 300 – not from hospitals• Inducible clindamycin resistance• Recurrent in 10-23%• More easily spread

Zafar U, Johnson LB, et al. Prevalence of nasal colonization among patients with community-associated methicillin-resistant Staphylococcus aureus infection and

their household contacts. Infect Control Hosp Epidemiol. 2007;28(8):966-9.

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA





genes (Panton-Valentine leukocidin)• USA 300 – not from hospitals• Inducible clindamycin resistance• Recurrent in 10-23%• More easily spread• Necrotizing more often than MSSA

Wang JL, et al. Comparison of both clinical features and mortality risk associated with bacteremia due to community-acquired methicillin-resistant Staphylococcus aureus and methicillin-susceptible S. aureus. Clin Infect Dis. 2008;46(6):799-806

.

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA





genes (Panton-Valentine leukocidin)• USA 300 – not from hospitals• Inducible clindamycin resistance• Recurrent in 10-23%• More easily spread• Necrotizing more often than MSSA• Outcomes are worse

Davis SL, Perri MB, et al. Epidemiology and outcomes of community-associated methicillin-resistant Staphylococcus aureus infection. J Clin Microbiol.

2007;45(6):1705

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA




percentage are MRSA+? SSTI incidence increasing since MRSA

emergence

Pallin DJ, et al. Increased US emergency department visits for skin and soft tissue infections, and changes in antibiotic choices, during the emergence of community-

associated methicillin-resistant Staphylococcus aureus. Ann Emerg Med. 2008 Mar;51(3):291-8

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA




percentage are MRSA+?

Many studies looking at prevalence

Moran GJ, et al. Methicillin-resistant S. aureus infections among patients in the emergency department. N Engl J Med. 2006;355(7):666-74

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA




percentage are MRSA+?

Risk factors for MRSA include:

Frazee BW, et al. High prevalence of MRSA in emergency department skin and soft tissue infections. Ann Emerg Med. 2005;45(3):311-20

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5

ANESTHESIA



ABSCESS QUESTION 6:Do I need to cover

with antibiotics after I&D?

NEC FASC

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA

ABSCESS: Q5



ABSCESS

LRINEC

QUESTION 6: Do I need to cover with antibiotics

after I&D? Burn et al 1957: PCN effective after I&D despite very high rates of resistanceNEC FASC

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA



ABSCESSQUESTION 6: Do I need to cover with antibiotics

after I&D? Burn et al 1957: PCN effective after I&D despite very high rates of resistance

Many studies: I&D alone is effectiveMacfie J, Harvey J. The treatment of acute superficial abscesses: a

prospective clinical trial. Br J Surg 1977; 64:264–6

Stewart MP, Laing MR, Krukowski ZH. Treatment of acute abscesses by incision, curettage and primary suture without antibiotics: a controlled

clinical trial. Br J Surg. 1985 Jan;72(1):66-7

Llera JL, Levy RC. Treatment of cutaneous abscess: a double-blind clinical study. Ann Emerg Med 1985; 14:15–9

LRINEC

NEC FASC

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA




after I&D?

I&D vs I&D + cephalexin equivalent (10% failure)

LRINEC

NEC FASC

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA




after I&D?

“Incision and drainage without adjunctive antibiotic therapy was effective management of CA-MRSA skin and soft tissue abscesses with a diameter of <5 cm in immunocompetent children.”

LRINEC

NEC FASC

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA




after I&D?

• Retrospective: 492 pts, 531 MRSA+ abscesses• I&D alone – 13% failure rate• I&D + anti-MRSA Abx – 5% failure rate

Clinical Infectious Diseases. 2007;44:777-84

LRINEC

NEC FASC

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6

MRSA



ABSCESS: CDC RECS

NEC FASC: Q2


after I&D?


LRINEC

NEC FASC

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS

ABSCESS: Q6




ABSCESS: IDSA RECS

SUMMARY


after I&D?


Clin Infect Dis. 2005;41(10):1373-406

• I&D (A-I) packing not necessary• Culture not warranted (E-III)• Antibiotics not warranted in simple

abscess (E-III)• Eradication should be attempted in

outbreaks (B-III)

NEC FASC: Q2

LRINEC

NEC FASC

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS



ABSCESS: IDSA RECSQUESTION 6: Do I need to cover with antibiotics

after I&D?


Clin Infect Dis. 2005;41(10):1373-406

Outpt 1st line (A-I): • Tetracyclines, TMP-SMX, linezolid, +

other

Outpt 2nd line (kids, sulfa allergy) (A-I): • Clindamycin

SUMMARY

NEC FASC: Q2

LRINEC

NEC FASC

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS



ABSCESS: IDSA RECSQUESTION 6: Do I need to cover with antibiotics

after I&D?


Clin Infect Dis. 2005;41(10):1373-406

Inpt 1st line (A-I):• vancomycin, daptomycin, linezolid

Inpt 2nd line:• TMP-SMX, rifampin

SUMMARY

NEC FASC: Q2

LRINEC

NEC FASC

NEC FASC: Q1

NEC FASC

IDSA

CDC

ANTIBIOTICS



NECROTIZING INFECTIONS

THE END

SUMMARY

NEC FASC: Q2

LRINEC

NEC FASC

NEC FASC: Q1

NEC FASC

IDSA

CDC



Type I: PolymicrobialType II: Monomicrobial

GAS accounts for 25-50%MRSA is a cause

NECROTIZINGINFECTIONS

THE END

SUMMARY

NEC FASC: Q2

LRINEC

NEC FASC

NEC FASC: Q1

NEC FASC

IDSA

CDC



Mortality – 34%

Antibiotics:• Prevent overwhelming sepsis• No role in cure

NECROTIZINGINFECTIONS

Green RJ, Dafoe DC, Raffin TA: Necrotizing fasciitis. Chest 1996; 110:219–229

THE END

SUMMARY

NEC FASC: Q2

LRINEC

NEC FASC

NEC FASC: Q1

NEC FASC

IDSA

CDC



NEC FASC QUESTION 1:

When should I consider necrotizing

fasciitis?

THE END

SUMMARY

NEC FASC: Q2

LRINEC

NEC FASC

NEC FASC: Q1

NEC FASC

IDSA



NEC FASCQUESTION 1: When should I

consider nec fasc?

Anaya DA, Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clin Inf Dis. 2007; 44:705-10

• Pain out of proportion

• Violaceous bullae• Cutaneous

hemorrhage• Skin sloughing

• Skin anesthesia• Rapid progression• Gas in the tissue• Skip lesions

THE END

SUMMARY

NEC FASC: Q2

LRINEC

NEC FASC

NEC FASC: Q1

NEC FASC



NEC FASCQUESTION 1: When should I

consider nec fasc?

Retrospective, observational• Derivation cohort (89/314)• Validation cohort (56/140)

Wong CH, et al. The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score: a tool for distinguishing necrotizing fasciitis from other soft

tissue infections. Crit Care Med. 2004;32(7):1535-41

THE END

SUMMARY

NEC FASC: Q2

LRINEC

NEC FASC

NEC FASC: Q1



LRINEC SCOREQUESTION 1: When should I

consider nec fasc?



≤2.5>2.5

≤180>180

THE END

SUMMARY

NEC FASC: Q2

LRINEC

NEC FASC

NEC FASC: Q1




consider nec fasc?



THE END

SUMMARY

NEC FASC: Q2

LRINEC

NEC FASC

NEC FASC: Q1




consider nec fasc?

145 cases of NF• 2 had score < 5• 2 had score = 5

Using cutoff of < 6• PPV = 92%• NPV = 96%



THE END

SUMMARY

NEC FASC: Q2

LRINEC

NEC FASC

NEC FASC: Q1



NEC FASC QUESTION 2:

Which antibiotic should I use in

necrotizing fasciitis?

THE END

SUMMARY

NEC FASC: Q2

LRINEC

NEC FASC



NEC FASC: IDSA RECSQUESTION 2: Which antibiotic should I use in

nec fasc?


Clin Infect Dis. 2005;41(10):1373-406

Surgery is the definitive tx (A-III)

Necrotizing fasciitis from GAS:• clindamycin and penicillin (A-II)

Community-acquired mixed infections:• ampicillin-sulbactam plus clindamycin

plus ciprofloxacin (A-III)

THE END

SUMMARY

NEC FASC: Q2

LRINEC

NEC FASC



TAKE HOME: CELLULITIS1. No cultures in uncomplicated

cellulitis

2. Don’t automatically cover MRSA

THE END

SUMMARY

NEC FASC: Q2

LRINEC



TAKE HOME: ABSCESS

1. I&D all abscesses

2. Wick, don’t pack

3. Assume MRSA

4. Antibiotics if >5cmTMP-SMX or doxycycline +

THE END

SUMMARY

NEC FASC: Q2

LRINEC



TAKE HOME: NEC FASC

1. Surgery is the treatment

2. Use the LRINEC (for now)

THE END

SUMMARY

NEC FASC: Q2

LRINEC



THANKS!THE END

SUMMARY

NEC FASC: Q2

Skin and Soft Tissue Infections

Health & Medicine

infectious

laboratory

q1 risk fx

prospective

blind clinical

clin infect

easily spread

controlled