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Skin and Soft Tissue Infections

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Nathan Cleveland, MD, MS

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Skin and Soft Tissue Infections

  1. 1. EVIDENCE-BASED MANAGEMENT NATHAN CLEVELAND, MD, MS UNIVERSITY MEDICAL CENTER 22 AUGUST 2012
  2. 2. EVIDENCE-BASED MANAGMENT “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
  3. 3. EVIDENCE-BASED MANAGMENT “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
  4. 4. EVIDENCE-BASED MANAGMENT “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.” 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
  5. 5. EVIDENCE-BASED MANAGMENT CELLULITIS 1. Review skin anatomy 2. Describe types of SSTIs 3. Current best evidence • Diagnosis • Management 4. Highlight CDC and IDSA recommendations FAQs VISUAL I.D. SSTI OVERVIEW GOALS INTRO HISTORY NOT GOALS ANATOMY
  6. 6. EVIDENCE-BASED MANAGMENT vs ERYSIPELAS 1. 2. 3. 4. CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW GOALS INTRO NOT GOALS ANATOMY
  7. 7. EVIDENCE-BASED MANAGMENT 5. vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW GOALS INTRO NOT GOALS ANATOMY
  8. 8. EVIDENCE-BASED MANAGMENT RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW GOALS NOT GOALS ANATOMY
  9. 9. EVIDENCE-BASED MANAGMENT 1. Bacterial, fungal, viral, parasitic 2. Focus on bacterial 3. Classified based on depth 4. Many names – SSTI, cSSSI, ABSSSI CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW NOT GOALS ANATOMY
  10. 10. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  11. 11. EVIDENCE-BASED MANAGMENT Infectious epidermal eruptions of flaccid pustules, which rupture to form a thick honey-colored to brown crust. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  12. 12. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  13. 13. EVIDENCE-BASED MANAGMENT Inflammation of the hair follicle that appears clinically as an eruption of pustules and/or papules centered upon hair follicles. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  14. 14. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  15. 15. EVIDENCE-BASED MANAGMENT An ulcerative pyoderma of the skin often referred to as a deeper form of impetigo. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  16. 16. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  17. 17. EVIDENCE-BASED MANAGMENT Acute beta-hemolytic group A streptococcal infection of the skin involving the superficial dermal lymphatics that causes marked swelling. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  18. 18. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  19. 19. EVIDENCE-BASED MANAGMENT Deep subcutaneous infection of the skin that results in a localized area of erythema and inflammation. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  20. 20. EVIDENCE-BASED MANAGMENT All that is red is not cellulitis! CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  21. 21. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  22. 22. EVIDENCE-BASED MANAGMENT Localized infection with accumulation of PMN leukocytes with tissue necrosis involving the dermis and subcutaneous tissue. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  23. 23. EVIDENCE-BASED MANAGMENT CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  24. 24. EVIDENCE-BASED MANAGMENT An infection of the deeper layers of skin and subcutaneous tissues which spreads along fascial planes. Type I = polymicrobial infection, Type II = monomicrobial infection. CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW ANATOMY
  25. 25. EVIDENCE-BASED MANAGMENT CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D. SSTI OVERVIEW
  26. 26. EVIDENCE-BASED MANAGMENT BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs VISUAL I.D.
  27. 27. EVIDENCE-BASED MANAGMENT • Dermal and subdermal • Ill-defined • Indolent • Less systemic symptoms CELLULITIS: Q3 • Dermal lymphatics • Well-demarcated • Acute onset • More systemic symptoms BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS FAQs
  28. 28. EVIDENCE-BASED MANAGMENT IMAGING IMMUNOCOMPROMISE LYMPHEDEMA VASCULAR INSUFFICIENCY OBESITY TINEA / INTERTRIGO CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS CELLULITIS
  29. 29. EVIDENCE-BASED MANAGMENT CELLULITIS: Q4 IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX vs ERYSIPELAS
  30. 30. EVIDENCE-BASED MANAGMENT 1. Few studies, none recent 2. Vary widely in success ORGANISMS CELLULITIS: Q4 IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX
  31. 31. EVIDENCE-BASED MANAGMENT 1. Few studies, none recent 2. Vary widely in success ORGANISMS CELLULITIS: Q4 IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX
  32. 32. EVIDENCE-BASED MANAGMENT 1. Few studies, none recent 2. Vary widely in success 3. Not cost effective, rarely changes management ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1 RISK FX
  33. 33. EVIDENCE-BASED MANAGMENT CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE CELLULITIS: Q1
  34. 34. EVIDENCE-BASED MANAGMENT MRSA • Meta-analysis: 5 studies, 844 pts • Mostly inpatients CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE
  35. 35. EVIDENCE-BASED MANAGMENT • 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
  36. 36. EVIDENCE-BASED MANAGMENT MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2 CULTURE
  37. 37. EVIDENCE-BASED MANAGMENT CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3 BLOOD Cx CELLULITIS: Q2
  38. 38. EVIDENCE-BASED MANAGMENT • Often “soft” findings on XR, US, CT • No studies on imaging cellulitis • XR reasonable for foreign body ANTIBIOTICS 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
  39. 39. EVIDENCE-BASED MANAGMENT CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING CELLULITIS: Q3
  40. 40. EVIDENCE-BASED MANAGMENT IDSA RECS Erysipelas = strep CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING
  41. 41. EVIDENCE-BASED MANAGMENT • 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
  42. 42. EVIDENCE-BASED MANAGMENT • 66% isolates = strep IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a IMAGING
  43. 43. EVIDENCE-BASED MANAGMENT • 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
  44. 44. EVIDENCE-BASED MANAGMENT • 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
  45. 45. EVIDENCE-BASED MANAGMENT ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS CELLULITIS: Q4a
  46. 46. EVIDENCE-BASED MANAGMENT • CA-MRSA is most common cause of “purulent” cellulitis in the ED ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS
  47. 47. EVIDENCE-BASED MANAGMENT • Assume CA-MRSA causes “non- purulent” cellulitis sometimes • But... Probably not as common ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b ORGANISMS
  48. 48. EVIDENCE-BASED MANAGMENT ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA CELLULITIS: Q4b
  49. 49. EVIDENCE-BASED MANAGMENT ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA
  50. 50. EVIDENCE-BASED MANAGMENT 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
  51. 51. EVIDENCE-BASED MANAGMENT 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 Homeless Jail IVDU Recent hospitalization / Abx ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS ANTIBIOTICS CELLULITIS: Q5 MRSA
  52. 52. EVIDENCE-BASED MANAGMENT 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
  53. 53. EVIDENCE-BASED MANAGMENT 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
  54. 54. EVIDENCE-BASED MANAGMENT 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
  55. 55. EVIDENCE-BASED MANAGMENT 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 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
  56. 56. EVIDENCE-BASED MANAGMENT 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 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
  57. 57. EVIDENCE-BASED MANAGMENT 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 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
  58. 58. EVIDENCE-BASED MANAGMENT IMAGING ABSCESS: Q3 PACKING ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS CDC RECS
  59. 59. EVIDENCE-BASED MANAGMENT ABSCESS: Q4 IMAGING ABSCESS: Q3 PACKING ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1 ABSCESS IDSA RECS
  60. 60. EVIDENCE-BASED MANAGMENT ANESTHESIA 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
  61. 61. EVIDENCE-BASED MANAGMENT 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
  62. 62. EVIDENCE-BASED MANAGMENT 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
  63. 63. EVIDENCE-BASED MANAGMENT ABSCESS: Q5 ANESTHESIA ABSCESS: Q4 IMAGING ABSCESS: Q3 PACKING ABSCESS: Q2 ABSCESS I&D ABSCESS: Q1
  64. 64. EVIDENCE-BASED MANAGMENT MRSA 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
  65. 65. EVIDENCE-BASED MANAGMENT ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA ABSCESS: Q4 IMAGING ABSCESS: Q3 PACKING ABSCESS: Q2
  66. 66. EVIDENCE-BASED MANAGMENT ANTIBIOTICS 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
  67. 67. EVIDENCE-BASED MANAGMENT 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
  68. 68. EVIDENCE-BASED MANAGMENT CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA ABSCESS: Q4 IMAGING ABSCESS: Q3
  69. 69. EVIDENCE-BASED MANAGMENT IDSA 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
  70. 70. EVIDENCE-BASED MANAGMENT 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
  71. 71. EVIDENCE-BASED MANAGMENT NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5 ANESTHESIA ABSCESS: Q4
  72. 72. EVIDENCE-BASED MANAGMENT NEC FASC: Q1 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
  73. 73. EVIDENCE-BASED MANAGMENT MRSA carries additional virulence 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
  74. 74. EVIDENCE-BASED MANAGMENT MRSA carries additional virulence 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
  75. 75. EVIDENCE-BASED MANAGMENT MRSA carries additional virulence 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
  76. 76. EVIDENCE-BASED MANAGMENT MRSA carries additional virulence 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
  77. 77. EVIDENCE-BASED MANAGMENT MRSA carries additional virulence 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
  78. 78. EVIDENCE-BASED MANAGMENT MRSA carries additional virulence 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
  79. 79. EVIDENCE-BASED MANAGMENT 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
  80. 80. EVIDENCE-BASED MANAGMENT 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
  81. 81. EVIDENCE-BASED MANAGMENT 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
  82. 82. EVIDENCE-BASED MANAGMENT NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA ABSCESS: Q5
  83. 83. EVIDENCE-BASED MANAGMENT LRINEC Burn et al 1957: PCN effective after I&D despite very high rates of resistance NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA
  84. 84. EVIDENCE-BASED MANAGMENT Burn et al 1957: PCN effective after I&D despite very high rates of resistance Many studies: I&D alone is effective Macfie 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
  85. 85. EVIDENCE-BASED MANAGMENT I&D vs I&D + cephalexin equivalent (10% failure) LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6 MRSA
  86. 86. EVIDENCE-BASED MANAGMENT “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
  87. 87. EVIDENCE-BASED MANAGMENT • 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
  88. 88. EVIDENCE-BASED MANAGMENT NEC FASC: Q2 http://www.cdc.gov/mrsa/mrsa_initiative/skin_infection/mrsa_algorithm.html LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC ANTIBIOTICS ABSCESS: Q6
  89. 89. EVIDENCE-BASED MANAGMENT SUMMARY 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 • 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
  90. 90. EVIDENCE-BASED MANAGMENT 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 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
  91. 91. EVIDENCE-BASED MANAGMENT 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 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
  92. 92. EVIDENCE-BASED MANAGMENT THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC
  93. 93. EVIDENCE-BASED MANAGMENT Type I: Polymicrobial Type II: Monomicrobial GAS accounts for 25-50% MRSA is a cause THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA CDC
  94. 94. EVIDENCE-BASED MANAGMENT Mortality – 34% Antibiotics: • Prevent overwhelming sepsis • No role in cure 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
  95. 95. EVIDENCE-BASED MANAGMENT THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1 NEC FASC IDSA
  96. 96. EVIDENCE-BASED MANAGMENT 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
  97. 97. EVIDENCE-BASED MANAGMENT 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
  98. 98. EVIDENCE-BASED MANAGMENT 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 ≤2.5 >2.5 ≤180 >180 THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC NEC FASC: Q1
  99. 99. EVIDENCE-BASED MANAGMENT 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
  100. 100. EVIDENCE-BASED MANAGMENT 145 cases of NF • 2 had score < 5 • 2 had score = 5 Using cutoff of < 6 • PPV = 92% • NPV = 96% 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
  101. 101. EVIDENCE-BASED MANAGMENT THE END SUMMARY NEC FASC: Q2 LRINEC NEC FASC
  102. 102. EVIDENCE-BASED MANAGMENT 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 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
  103. 103. EVIDENCE-BASED MANAGMENT 1. No cultures in uncomplicated cellulitis 2. Don’t automatically cover MRSA THE END SUMMARY NEC FASC: Q2 LRINEC
  104. 104. EVIDENCE-BASED MANAGMENT 1. I&D all abscesses 2. Wick, don’t pack 3. Assume MRSA 4. Antibiotics if >5cm TMP-SMX or doxycycline + THE END SUMMARY NEC FASC: Q2 LRINEC
  105. 105. EVIDENCE-BASED MANAGMENT 1. Surgery is the treatment 2. Use the LRINEC (for now) THE END SUMMARY NEC FASC: Q2 LRINEC
  106. 106. EVIDENCE-BASED MANAGMENT THE END SUMMARY NEC FASC: Q2

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