Keri Holmes-Maybank, MD Medical University of South Carolina Cellulitis Impetigo Erysipelas Abscess Animal bite Human bite Surgical site infection Necrotizing fasciitis.
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Keri Holmes-Maybank, MD Medical University of South Carolina Cellulitis Impetigo Erysipelas Abscess Animal bite Human bite Surgical site infection Necrotizing fasciitis 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 “Practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate health care for specific clinical circumstances.” 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 Decreased costs No change in adverse outcomes Systemic illness ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ HR >100 and Temp >38oC or <36oC and Systolic bp <90 or decrease of 20 mmHg < baseline CRP>13 Marked left shift Elevated creatinine Low serum bicarbonate CPK 2 x the upper limit of normal Abnormally 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 Indicators of more severe disease: ◦ ◦ ◦ ◦ ◦ ◦ Low sodium Low bicarb High creatinine New anemia Low or high wbc High CRP (associated with longer hospitalization) Blood cultures positive <5% Needle aspiration 5-40% Punch biopsy 20-30% HR >100 , Temp >38oC and <36oC, Sys <90mmHg Lymphedema Immune compromise/neutropenia/malignancy Pain out of proportion to exam Infected mouth or eyes Unresponsive to initial antibiotics Water-associated cellulitis Diabetes Recurrent or persistent cellulitis Concern for a cluster or outbreak HR >100 , Temp >38oC and <36oC, Sys<90mmHg ◦ 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 Immune status Geographic locale Travel history Recent trauma or surgery Previous antimicrobial therapy Lifestyle - occupation Hobbies Animal exposure Bite exposure If no improvement in systemic signs in 48 hours If no improvement in skin in 72 hours As antibiotics kill organisms, released toxins may cause a worsening of skin findings in first 48 hours 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 65% relative increase since 1999 600,000 admissions annually Obesity Edema Fissured toe webs ◦ Venous insufficiency ◦ Lymphatic obstruction ◦ 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 Saphenous venectomy Axillary node dissection for breast cancer Gyn malignancy surgery with lymph node dissection *** in conjuction with XRT Liposuction CBC with diff BMP Blood cultures Culture aspiration of leading edge of cellulitis INTACT SKIN No purulent drainage, no exudate, no associated abscess Beta hemolytic streptococci Antibiotic: ◦ Cefazolin ◦ Documented anaphylactic cephalosporin allergy Vancomycin Deescalation: ◦ Cephalexin ◦ Beta-lactam anaphylaxis - clindamycin 5 days of treatment BROKEN SKIN Purulent drainage Exudate Absence of a drainable abscess MRSA coverage Antibiotics: ◦ Vancomycin Deescalation: ◦ Trimethoprim/sulfamethoxazole + cephalexin ◦ Beta lactam anaphylaxis – clindamycin ◦ Sulfa allergy – tetracycline or doxycycline ◦ If sulfa and beta lactam allergies - linezolid 5 days of treatment Empiric SSTI algorithm *This algorithm does NOT include: surgical site infections, diabetic foot ulcers, decubitus ulcers, insect, animal or human bites, or gangrene **Please see order form for guidance (including renal dosing adjustments) Abscess1 Empiric Adult SSTI Nonnecrotizing SSTI Necrotizing Fasciitis Purulent Cellulitis (Complicated) Intact Skin Cellulitis (Uncomplicated) Vancomycin Drainable? Yes < 3 cm I&D; No Cx; No antibiotics Yes >3 cm; I&D and culture (exudate aerobic only) Vancomycin (25-30 mg/kg; doses > 2 grams contact PharmD on call) IV x 1, then (15 mg/kg) IV Cefazolin 1 (25-30 mg/kg; doses > 2 grams contact PharmD on call) IV x 1, then (15 mg/kg) IV No – Treat if I&D is NOT possible Vancomycin (25-30 mg/kg; doses > 2 grams contact PharmD on call) IV x 1, then (15 mg/kg) IV ( Immediate ID and surgical consult for STAT debridement - 2 gram IV Q8H x 5 days If cephalosporin allergic: Vancomycin can be substituted for cefazolin The preferred method of treatment is I&D 1 Clinical Pearl: Treatment should continue for 48 hours prior to determination of clinical failure; SSTIs often appear worse during initial treatment period Antibiotic De-escalation Criteria 1. Culture susceptibilities 2. Clinical response 1. Clinically stable 2. Decreased erythema 3. Decreased edema 4. Decreased warmth 5. Resolving leukocytosis 6. Afebrile Empiric Adult SSTI – Antibiotic De-escalation Non-purulent Cellulitis INTACT SKIN (Uncomplicated) Purulent Cellulitis NON-INTACT SKIN (Complicated) Completely Drained Abscess Non-drainable Abscess Cephalexin 500 mg PO Q 6 H (to complete 5 day total course) TMP/SMX 160/800 mg PO Q 12 H plus Cephalexin 500 mg PO Q 6 H (to complete 5 day total course) TMP/SMX 160/800 mg PO Q 12 H plus Cephalexin 500 mg PO Q 6 H (to complete 5 day total course) TMP/SMX 160/800 mg PO Q 12 H plus Cephalexin 500 mg PO Q 6 H (to complete 5 day total course) Total course of antibiotics is 5 days (i.e. 2 days of IV cefazolin + 3 days of PO cephalexin) Note: Renal dose adjustments are required for patients with CrCL less than 30 mL/min If sulfa allergic: Either tetracycline or doxycycline can be substituted to replace TMP/SMX If beta-lactam anaphylaxis: Clindamycin (non-severe infection) can be substituted to replace cephalexin, or linezolid can be substituted to replace both TMP/SMX and cephalexin Elevation of affected leg Compression stockings Treat underlying tinea pedis, eczema, trauma Keep skin well hydrated Acute dermatitis Lipodermatosclerosis Deep vein thrombosis Contact dermatitis Drug reaction Foreign body reaction Gout Herpes zoster ALWAYS, ALWAYS ◦ Incision and drainage Incision and drainage No blood cultures No aspirate culture NO ANTIBIOTICS CBC with diff BMP Blood cultures Culture exudate Drainable abscess >3cm Undrainable 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 MRSA coverage Antibiotic: ◦ Vancomycin Deescalation: ◦ Trimethoprim/sulfamethoxazole + cephalexin ◦ Beta lactam anaphylaxis – clindamycin ◦ Sulfa allergy – tetracycline or doxycycline ◦ If sulfa and beta lactam allergies - linezolid Treatment duration: ◦ Usually 5 days of treatment – 10 maximum Pasteurella – mc organism Antibiotics: ◦ ◦ ◦ ◦ ◦ Ampicillin/sulbactam Piperacillin/tazobactan Cefoxitin Meropenem Ertapenem (restricted to ID and Surgery) Tetanus toxoid (if not up to date) Deescalation ◦ Amoxicillin/clavulanate ◦ Doxycycline Treatment duration: ◦ Discontinue abx 3 days after acute inflammation disappears ◦ Usually 5-10 days of treatment 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*** 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 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 If temperature >38.5oC or HR >100 bpm: Trunk, head, neck, extremity Perineum, gi tract, female gu tract Treatment duration: ◦ Cefazolin ◦ Clindamycin ◦ Vancomycin if MRSA is suspected ◦ ◦ ◦ ◦ Cefotetan Ampicillin/sulbactam Ceftriaxone + metronidazole or clindamycin Fluoroquinolone + clindamycin ◦ Usually 24-48 hours or for 3 days after acute inflammation resolves ALWAYS blood CULTURES Initial infection - <7 days neutropenia Antibiotics ◦ ◦ ◦ ◦ Carbapenems Cefepime Ceftazidine Piperacillin/tazobactam ◦ ◦ ◦ ◦ Vancomycin Linezolid (restricted to ID) Daptomycin (restricted to ID) (discontinue if culture negative after 72-96 hours) PLUS 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 ◦ ◦ ◦ ◦ Vancomycin Linezolid (restricted to ID) Daptomycin (restricted to ID) (discontinue if culture negative after 72-96 hours) PLUS Deescalation: ◦ Ciprofloxacin and amoxicillin/clavulanate Treatment duration: ◦ At least 7 days Device predisposes to SSTI 66% Gram positive Entry site infection ◦ Antibiotics Tunnel infection and vascular port-pocket infection ◦ Device removal and antibiotics Not all diabetic foot ulcers are infected. Infection if at least 2 present: Purulent secretions Redness Warmth Swelling/induration Pain/tenderness Common, complex, costly Largest number of diabetes-related hospital bed days Most common proximate, non-traumatic cause of amputations Recent hospitalization last 90 days Residence in long term care facility Antibiotics last 90 days Injection drug use Hemo- or peritoneal dialysis Incarceration last 90 days Home infusion therapy History of MRSA colonization Immunosupressive state/medications Wound care in past 30 days ICU stay in last 90 days Immunosuppressive state/medications Immunosuppressive states includes: ◦ HIV, solid organ transplants, BMT Immunosuppressive medications includes: ◦ Rejection medications, >20mg/d prednisone x2w Cellulitis or erythema extends <2cm around ulcer, infection limited to skin – no systemic indications Obtain foot xray – screen for osteomyelitis Antibiotics: ◦ No MRSA risk: Cephalexin Amoxicillin/clavulanate ◦ MRSA risk: Trimethoprim/sulfamethoxazole Doxycycline Treatment duration ◦ Usually 1-2 weeks treatment (can be as long as 4 weeks) Erythema extends >2cm around ulcer or signs of abscess, osteomyelitis, septic arthritis, fasciitis – no systemic signs Foot x-ray Culture wound Wound care Assess need for debridement general surgery CRP ESR Bone biopsy for culture MRI if ESR and CRP elevated ID consult if osteomyelitis present Erythema extends >2cm around ulcer and signs of systemic infection(hypotension, hyperthermia, tachycardia) Foot xray Culture wound Blood cultures Wound care Assess need for debridement general surgery CRP ESR Consider MRI if suspect abscess or uncertain if osteomyelitis or if the ESR and CRP Bone biopsy ID consult if osteomyelitis Wound care Debridement Glycemic control Evaluate vascular status Cards Not on cpoe or clinician order forms Quality Starts now – review at end of June 2013 Algorithm – antibiotics Questions for Dr. Gomez or Dr. Hurst? Gunderson CG. Cellulitis: Definition, etiology, and clinical features. Am J Med 2011;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 2001;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. MUSC Antibiotic Stewardship – Drs. Juan Manual Gomez, Sean Boger, John Hurst.