Skin and SoftTissue Infections Superficial lesions vs Deadly disease Outpatient Management and Indic

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Skin and Soft-Tissue InfectionsSuperficial
lesions vs Deadly diseaseOutpatient Management
and Indications for Hospitalization

• Nayef El-Daher, MD, PhD
• Richard Magnussen, MD
• J Crit Illness, 1998 13(3)151-160

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Skin and soft-tissue Infections

• Localized infections
• cellulitis
• erysipelas
• Potentially lethal infections
• necrotizing fascitis
• myonecrosis
• pyomyositis

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Cellulitis and Erysipelas pathogenesis

• Cellulitis
• group A streptococci typically follows an
  innocuous or unrecognized injury inflammation is
  diffuse, spreading along tissue planes
• staphylococcus aureususually associated with
  wound or penetrating trauma localized abscess
  become surrounded by cellulitis

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Cellulitis and Erysipelas pathogenesis

• Erysipelas
• caused most often by group A streptococci
• rarely cased by ß-hemolytic streptococci of the
  B, C, or G serologic group

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Cellulitis and Erysipelas diagnosis

• General features
• varying degrees of skin or soft-tissue erythema,
  warmth, edema, and pain
• associated fever and leukocytosis
• history of trauma, abrasion, or skin ulceration
  (not reported by every patient)

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Cellulitis and Erysipelas diagnosis

• physical exam
• cellulitis has an ill-defined border that merge
  smoothly with adjacent skin usually pinkish to
  redish
• erysipelas has an elevated and sharply demarcated
  border with a fiery-red appearance

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Cellulitis and Erysipelas diagnosis

• laboratory exam
• needle aspiration of the leading edge of the
  cellulitis should be obtained (1)
• elevated antistrptolysin O titer supports
  diagnosis of streptococcal infection
• blood cultures for patients with symptoms of
  toxicity or temp gt 1020F

1. Arch Intern Med 1990 1501907-1912
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Cellulitis and Erysipelas management

• Local care
• immobilization
• elevation to reduce swelling
• 2 weeks of antibiotic therapy
• penicillin and dicloxacillin for most pts
• many new, potent and expensive antibiotics offer
  no advantage

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Outpatient Therapy

• Infection Most patients Pencillin allergic
  patients
• Cellulitis
• mild-mod Dicloxacillin Cephalexin 500mg po q6h
• (500 mg po q6h) Clindamycin 450mg po q6h
• severe Nafcillin 1-2g iv q4h Cefazolin 1g iv
  q8h
• Vancomycin 1g iv q12h
• Erysipelas
• mild-mod Penicillin V Cephalexin 500mg po q6h
• (500 mg po q6h) Erythromycin 500mg po q6h
• Clindamycin 450mg po q6h
• severe Pen G 1-2 million U q6h Cefazolin 1g iv
  q8h
• Clindamycin 900mg iv q8h

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Admission Criteria for Cellulitis

• Animal bite on patients face or hand
• Area of skin involvement gt50 of limb or torso,
  or gt10 of body surface
• Coexisting morbidity (diabetes, heart failure,
  renal failure, generalized edema)
• Edge of cellulitis advancing at rate exceeding
  5cm, or 2 in, per hour
• History of saphenous venectomy, pelvic surgery,
  pelvic irradiation, or neoplastic pelvic lymph
  nodes (with lower extremity cellulitis)

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Admission Criteria for Cellulitis

• Immunosuppression
• Intolerance of oral or IM antibiotic therapy
• Lack of response after 72 hours of oral therapy
• Noncompliance with medication and follow-up
  visits
• Purpuric or petechial rash, numbness at skin
  surface, or impaired tendon or nerve function
• shock or disseminated intravascular coagulation
• Signs and symptoms suggestive of bacteremia
• Total WBC lt 1000 / uL

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Necrotizing Fasciitispathogenesis

• a polymicrobial infection, commonly caused by a
  mixture of anaerobic and aerobic bacteria
• clostridium species, enterobacteriaceae ( E.
  coli, Enterobacter, Klebsiella, and Proteus
  species), and flesh-eating streptococci
• usually starts at the site of nonpenetrating
  trauma (a bruise)

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Necrotizing Fasciitisdiagnostic clues

• Underlying diabetes mellitus, peripheral vascular
  disease, alcoholism, intravenous drug use or
  immunosupression
• Most often involve the lower extremities
• Infected area is swollen, erythematous, painful,
  warm, and very tender
• Rapidly advancing border (5 cm, or 2 in, per
  hour) of discoloration (red to blue-gray)

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Necrotizing Fasciitisdiagnostic clues

• Bulllae formation and cutaneous gangren
• Frank pus in discolored area (revealed by needle
  aspiration or surgical exploration)
• Numerous bacteria evident on the Gram stain
• Tendon or nerve impairment (superficial nerve
  destruction and small vessel thrombosis)
• Systemic toxicity and/or hypotension

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Necrotizing Fasciitismanagement

• Immediate surgical debridement is critical and
  life saving
• empiric antibiotics to cover anaerobes, gram
  negative bacilli, streptococci, and Staph aureus
• penmetronidazoleclindamycinceftriaxone
• vancomycinchloramphenicol
• monotherapy with imipenem
• antibiotics for a minimum of 3 wks

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Myonecrosis (Gas Gangrene)

• a pure Clostridium perfringens infection
• gas in a gangrenous muscle group
• incubation period of hours to days
• local edema and pain accompanied by fever and
  tachycardia
• discharge is serosanguinous, dirty, and foul
• pen G (3-4 million U q4h) or chloramphenicol
• surgical removal of infected muscle

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Pyomyositis (tropical myositis)

• 50 with co-morbidity (diabetes, alcoholic liver
  disease, concurrent corticosteroid therapy,
  immunosuppression)
• endemic in the tropics
• area is indurated with a woody consistency
  erythema and tenderness is minimal initially
• fever and marked muscle tenderness may develop in
  1-3 weeks

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Pyomyositis (tropical myositis)

• Rhabdomyolysis - along with myoglobinuria and
  acute renal failure - may develop
• Staph aureus is the most common organism
• MRI or CT may show muscle enlargement
• surgical drainage is essential
• empiric antibiotics directed against Staph
• nafcillin 2 g iv q4h
• vancomycin 1 g iv q12h or cefazolin 1g iv q8h