skin and soft tissue infections
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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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
“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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
NOT GOALS
vs ERYSIPELAS1.
2.
3.
4.
CELLULITIS
FAQs
VISUAL I.D.
SSTI OVERVIEW
GOALS
INTRO
NOT GOALS
ANATOMY
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
NOT GOALS
5. vs ERYSIPELAS
CELLULITIS
FAQs
VISUAL I.D.
SSTI OVERVIEW
GOALS
INTRO
NOT GOALS
ANATOMY
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ANATOMY
RISK FX
vs ERYSIPELAS
CELLULITIS
FAQs
VISUAL I.D.
SSTI OVERVIEW
GOALS
NOT GOALS
ANATOMY
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CULTURE
CELLULITIS: Q1
RISK FX
vs ERYSIPELAS
CELLULITIS
FAQs
VISUAL I.D.
SSTI OVERVIEW
ANATOMY
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CULTURE
CELLULITIS: Q1
RISK FX
vs ERYSIPELAS
CELLULITIS
FAQs
VISUAL I.D.
SSTI OVERVIEW
ANATOMY
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CULTURE
CELLULITIS: Q1
RISK FX
vs ERYSIPELAS
CELLULITIS
FAQs
VISUAL I.D.
SSTI OVERVIEW
ANATOMY
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CULTURE
CELLULITIS: Q1
RISK FX
vs ERYSIPELAS
CELLULITIS
FAQs
VISUAL I.D.
SSTI OVERVIEW
ANATOMY
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CULTURE
CELLULITIS: Q1
RISK FX
vs ERYSIPELAS
CELLULITIS
FAQs
VISUAL I.D.
SSTI OVERVIEW
ANATOMY
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
All that is red is not cellulitis!
CELLULITIS?
CULTURE
CELLULITIS: Q1
RISK FX
vs ERYSIPELAS
CELLULITIS
FAQs
VISUAL I.D.
SSTI OVERVIEW
ANATOMY
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CULTURE
CELLULITIS: Q1
RISK FX
vs ERYSIPELAS
CELLULITIS
FAQs
VISUAL I.D.
SSTI OVERVIEW
ANATOMY
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CULTURE
CELLULITIS: Q1
RISK FX
vs ERYSIPELAS
CELLULITIS
FAQs
VISUAL I.D.
SSTI OVERVIEW
ANATOMY
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
THE QUESTIONS
CELLULITIS: Q2
CULTURE
CELLULITIS: Q1
RISK FX
vs ERYSIPELAS
CELLULITIS
FAQs
VISUAL I.D.
SSTI OVERVIEW
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS AND ERYSIPELAS
BLOOD Cx
CELLULITIS: Q2
CULTURE
CELLULITIS: Q1
RISK FX
vs ERYSIPELAS
CELLULITIS
FAQs
VISUAL I.D.
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
• 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS RISK FX
IMAGING
IMMUNOCOMPROMISE LYMPHEDEMA VASCULARINSUFFICIENCY
OBESITY TINEA /INTERTRIGO
CELLULITIS: Q3
BLOOD Cx
CELLULITIS: Q2
CULTURE
CELLULITIS: Q1
RISK FX
vs ERYSIPELAS
CELLULITIS
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
1. Few studies, none recent2. Vary widely in success
CELLULITISQUESTION 1: Should I try to
culture or biopsy cellulitis?
ORGANISMS
CELLULITIS: Q4
IMAGING
CELLULITIS: Q3
BLOOD Cx
CELLULITIS: Q2
CULTURE
CELLULITIS: Q1
RISK FX
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
1. Few studies, none recent2. Vary widely in success3. Not cost effective, rarely
changes management
CELLULITISQUESTION 1: Should I try to
culture or biopsy cellulitis?
ORGANISMS
CELLULITIS: Q4a
IMAGING
CELLULITIS: Q3
BLOOD Cx
CELLULITIS: Q2
CULTURE
CELLULITIS: Q1
RISK FX
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS QUESTION 2:
What about blood cultures?
CELLULITIS: Q4b
ORGANISMS
CELLULITIS: Q4a
IMAGING
CELLULITIS: Q3
BLOOD Cx
CELLULITIS: Q2
CULTURE
CELLULITIS: Q1
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITISQUESTION 2: What about
blood cultures?
MRSA
CELLULITIS: Q4b
ORGANISMS
CELLULITIS: Q4a
IMAGING
CELLULITIS: Q3
BLOOD Cx
CELLULITIS: Q2
CULTURE
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS QUESTION 3:
Do I need to image cellulitis?
CELLULITIS: Q5
MRSA
CELLULITIS: Q4b
ORGANISMS
CELLULITIS: Q4a
IMAGING
CELLULITIS: Q3
BLOOD Cx
CELLULITIS: Q2
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
• 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS QUESTION 4:
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ERYSIPELAS
IDSA RECS
QUESTION 4: Which
organisms cause cellulitis?
Erysipelas = strep
CDC RECS
ANTIBIOTICS
CELLULITIS: Q5
MRSA
CELLULITIS: Q4b
ORGANISMS
CELLULITIS: Q4a
IMAGING
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITISQUESTION 4: Which
organisms cause cellulitis?
• 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITISQUESTION 4: Which
organisms cause cellulitis?
• 66% isolates = strep
IDSA RECS
CDC RECS
ANTIBIOTICS
CELLULITIS: Q5
MRSA
CELLULITIS: Q4b
ORGANISMS
CELLULITIS: Q4a
IMAGING
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITISQUESTION 4: Which
organisms cause cellulitis?
• 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITISQUESTION 4: Which
organisms cause cellulitis?
• 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS QUESTION 4b:
Do I have to cover MRSA?
ABSCESS
IDSA RECS
CDC RECS
ANTIBIOTICS
CELLULITIS: Q5
MRSA
CELLULITIS: Q4b
ORGANISMS
CELLULITIS: Q4a
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
• 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
• 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS QUESTION 5:
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITISQUESTION 5: So then, what
antibiotic for cellulitis?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS: ABX RECSQUESTION 5: So then, what
antibiotic for cellulitis?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS: ABX RECSQUESTION 5: So then, what
antibiotic for cellulitis?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS: CDC RECS
PACKING
QUESTION 5: So then, what
antibiotic for cellulitis?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS: IDSA RECS
ABSCESS: Q3
QUESTION 5: So then, what
antibiotic for cellulitis?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS: IDSA RECS
QUESTION 5: So then, what
antibiotic for cellulitis?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS: IDSA RECS
QUESTION 5: So then, what
antibiotic for cellulitis?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
CELLULITIS: IDSA RECS
QUESTION 5: So then, what
antibiotic for cellulitis?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ABSCESSIMAGING
ABSCESS: Q3
PACKING
ABSCESS: Q2
ABSCESS I&D
ABSCESS: Q1
ABSCESS
IDSA RECS
CDC RECS
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ABSCESSQUESTION 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.
• 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ABSCESSQUESTION 1: How / why
should I I&D abscesses?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ABSCESS QUESTION 3:Should I image
abscesses?
ABSCESS: Q6
MRSA
ABSCESS: Q5
ANESTHESIA
ABSCESS: Q4
IMAGING
ABSCESS: Q3
PACKING
ABSCESS: Q2
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ABSCESS QUESTION 4:What is the best way
to anesthetize abscesses?
CDC
ANTIBIOTICS
ABSCESS: Q6
MRSA
ABSCESS: Q5
ANESTHESIA
ABSCESS: Q4
IMAGING
ABSCESS: Q3
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ABSCESS QUESTION 5:What percentage of
abscesses are MRSA+?
NEC FASC
IDSA
CDC
ANTIBIOTICS
ABSCESS: Q6
MRSA
ABSCESS: Q5
ANESTHESIA
ABSCESS: Q4
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
MRSA ABSCESSQUESTION 4: What
percentage are MRSA+? 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
MRSA ABSCESSQUESTION 4: What
percentage are MRSA+? 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
MRSA ABSCESSQUESTION 4: What
percentage are MRSA+? 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
MRSA ABSCESSQUESTION 4: What
percentage are MRSA+? 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
MRSA ABSCESSQUESTION 4: What
percentage are MRSA+? 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
MRSA ABSCESSQUESTION 4: What
percentage are MRSA+? 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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
MRSA ABSCESSQUESTION 4: What
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
MRSA ABSCESSQUESTION 4: What
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
MRSA ABSCESSQUESTION 4: What
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ABSCESSQUESTION 6: Do I need to cover with antibiotics
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ABSCESSQUESTION 6: Do I need to cover with antibiotics
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ABSCESSQUESTION 6: Do I need to cover with antibiotics
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ABSCESS: CDC RECS
NEC FASC: Q2
QUESTION 6: Do I need to cover with antibiotics
after I&D?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ABSCESS: IDSA RECS
SUMMARY
QUESTION 6: Do I need to cover with antibiotics
after I&D?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ABSCESS: IDSA RECSQUESTION 6: Do I need to cover with antibiotics
after I&D?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
ABSCESS: IDSA RECSQUESTION 6: Do I need to cover with antibiotics
after I&D?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
NECROTIZING INFECTIONS
THE END
SUMMARY
NEC FASC: Q2
LRINEC
NEC FASC
NEC FASC: Q1
NEC FASC
IDSA
CDC
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
LRINEC SCOREQUESTION 1: When should I
consider nec fasc?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
LRINEC SCOREQUESTION 1: When should I
consider nec fasc?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
LRINEC SCOREQUESTION 1: When should I
consider nec fasc?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
NEC FASC QUESTION 2:
Which antibiotic should I use in
necrotizing fasciitis?
THE END
SUMMARY
NEC FASC: Q2
LRINEC
NEC FASC
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
NEC FASC: IDSA RECSQUESTION 2: Which antibiotic should I use in
nec fasc?
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
TAKE HOME: CELLULITIS1. No cultures in uncomplicated
cellulitis
2. Don’t automatically cover MRSA
THE END
SUMMARY
NEC FASC: Q2
LRINEC
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
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
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
TAKE HOME: NEC FASC
1. Surgery is the treatment
2. Use the LRINEC (for now)
THE END
SUMMARY
NEC FASC: Q2
LRINEC
EVIDENCE-BASED MANAGMENT
SKIN AND SOFT TISSUE INFECTIONS
THANKS!THE END
SUMMARY
NEC FASC: Q2
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