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S A M P S O N R E G I O N A L M E D I C A L C E N T E R

INFECTIOUS DISEASES: BACTERIAL INFECTIONS

Laura Sandoval, DO, PGY-3Brianna McDaniel, DO, PGY-2Angela Macri, DO, PGY-2

OBJECTIVES

• Describe bacterial skin infections commonly seen in the

outpatient setting, including presentation, diagnosis, and

treatment.

• Discuss antibiotic resistance and current recommendations.

• Discuss dermatologic surgical site infections.

• Describe infections associated with cosmetic procedures.

Common Bacterial Infections

MRSA

• MC of skin and soft-tissue infections in US since 1970’s, prior was

Streptococcus pyogenes

• 2 major subtypes of S aureus: Methicillin-sensitive S aureus (MSSA) and

methicillin-resistant S aureus (MRSA)

• MRSA-community associated (CA): Development in individual w/out

h/o MRSA isolation or if + culture obtained in outpatient setting or w/in

48 hours of hospitalization

• Health care–associated (HA) MRSA: strain isolated in pt w/in 48 hours

of hospitalization w/ risk factors of resistant infection (dialysis, previous

colonization, surgery in past yr, a permanent medical device or

catheter, or hospital, hospice, or nursing home admission)

Lloyd KM, Schammel L. Clinical Progression of CA-MRSA Skin and Soft Tissue Infections: A New Look at an Increasingly

Prevalent Disease. Arch Dermatol. 2008;144(7):952-954.

MRSA

• Increased resistance to methicillin due to staphylococcal

chromosome cassette mec (SCC mec), specifically mecA gene.

• Panton-Valentine leukocidin (PVL): in many CA- MRSA strains,

associated with increased virulence(leukocyte destruction,

necrosis).

• TSST-1: Staph superantigen involved in toxic shock syndrome.

• Exfoliative toxin (ET-A, ET-B): has protease activity, splitting

desmoglein 1 at granular layer and can cause staphylococcal

scalded skin syndrome and bullous impetigo

Moran GJ, Abrahamian FM, LoVecchio F, Talan DA. Acute Bacterial Skin Infections: Developments Since the 2005

Infectious Diseases Society of America (IDSA) Guidelines. J Emerg Med. 2013 Jun;44(6)e397-e412.

ABSCESS

• MRSA can cause varied morphologies including abscesses,

cellulitis, furuncles, carbuncles, folliculitis, impetigo, or paronychia

to name a few.

• Abscesses: collections of pus within the dermis and deeper skin tissues

• Furuncle ("boil”): hair follicle infection in which purulent material extends through dermis into subcutaneous tissue small abscess forms

• Carbuncle: coalescence of several inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles

• back of neck, face, axillae, and buttocks are common areas of involvement

Lloyd KM, Schammel L. Clinical Progression of CA-MRSA Skin and Soft Tissue Infections: A New Look at an

Increasingly Prevalent Disease. Arch Dermatol. 2008;144(7):952-954.

MRSA

Medscape http://emedicine.medscape.com/article/228816-overview

MRSA



FURUNCLE

ABSCESS

• Skin and soft tissue caused by MRSA infections do not always

produce pus and abscesses.

• MC presenting symptom: inflammation and necrosis. Pain and

tenderness out of proportion to clinical presentation.

• Despite appropriate diagnosis and effective tx, response to tx

can exceed 6 weeks.

• DDx of lesions with necrotic papules with marked inflammation:

• brown recluse spider bites • cutaneous diphtheria

• cutaneous anthrax • vibrio vulnificus infections

• cutaneous tularemia



DDX FOR ABSCESS

• Other diagnoses to consider:

• Folliculitis

• Hidradenitis suppurativa

• Sporotrichosis

• Myiasis

• Botryomycosis

• Blastomycosis

Zabielinski M, McLeod M, Aber C, Izakovic J, Schachner L. Trends and antibiotic susceptibility patterns of

methicillin-resistant and methicillin-sensitive Staphylococcus aureus in an outpatient dermatology facility. JAMA

Dermatol. April 2013;149(4):427-432.



TREATMENT OF ABSCESSES

• Gram stain and culture are recommended, but treatment without these

studies is reasonable in typical cases.

• Incision and drainage (I&D) is the recommended treatment for inflamed

carbuncles, abscesses, and large furuncles.

• Patients with uncomplicated skin abscesses, I&D without administration of

antibiotics sufficient. • Administration of antibiotics as an adjunct should be made based upon presence or

absence of systemic inflammatory response syndrome (SIRS).

• Antibiotic coverage for MRSA is recommended for patients with

abscesses/carbuncles who have failed initial antibiotic treatment, have

markedly impaired host defenses, or in patients with SIRS and hypotension.

Stevens, D. “Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update

by the Infectious Diseases Society of America”. Infectious Diseases Society of America. 9/1/2015.

http://www.idsociety.org/Organ_System/#Skin%20&%20Soft%20Tissue

TREATMENT OF ABSCESSES

Stevens, D. “Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014

Update by the Infectious Diseases Society of America”. Infectious Diseases Society of America. 9/1/2015.


• Recurrent abscesses:

• I&D and culture early.

• Treat with a 5 to 10 day course of an antibiotic effective

against that pathogen.

• Consider a 5-day decolonization regimen twice daily of

intranasal Mupirocin, daily chlorhexidine washes, and daily

decontamination of personal items such as towels, sheets and

clothes for recurrent S. aureus infection.

SKIN SOFT TISSUE INFECTION TREATMENT




MSSA

Nafcillin or oxacillin 1-2 g q4h IV

Cefazolin 1g q8h IV

Clindamycin 600 mg q8h IV or 300-450 mg qid PO

Dicloxacillin 500 mg qid PO

Cephalexin 500 mg qid PO

Doxycycline or Minocycline 100 mg bid PO

Trimethoprim-Sulfamethoxazole 1-2 DS tab bid PO

SKIN SOFT TISSUE INFECTION TREATMENT




MRSA

Vancomycin 30 mg/kg/d in 2 divided doses IV

Linezolid 600 mg q12h IV or 600 mg bid PO

Clindamycin 600 mg q8h IV or 300-450 mg qid PO

Daptomycin 4 mg/kg every 24 h IV

Ceftaroline 600 mg bid IV

Doxycycline or Minocycline 100mg bid PO

Trimethoprim-Sulfamethoxazole 1-2 DS tab bid PO

IMPETIGO

• MC in children aged 2-5 years. MC infection in children

worldwide.

• Group A strep (Streptococcus pyogenes) previously MCC, but

now replaced by S. aureus.

• Nonbullous impetigo: accounts for 70% of cases erythematous

papules and thin-walled vesicles on face and extremities . Can

be painful. Usually resolve without tx in 2-3 weeks.

• Bullous impetigo: thin- roofed bullae and shallow erosions. S.

aureus almost always causative pathogen( phage II, type 71).

Develops in areas of trauma or intertriginous areas.

Bangert, S., Levy, M. and Hebert, A. A. Bacterial Resistance and Impetigo Treatment Trends: A Review. Pediatr

Dermatol. 2012;29: 243–248.

NON-BULLOUS IMPETIGO

http://www.merckmanuals.com/professional/dermatologic-disorders/bacterial-skin-infections/impetigo-and-ecthyma

BULLOUS IMPETIGO

http://www.merckmanuals.com/professional/dermatologic-disorders/bacterial-skin-infections/impetigo-and-ecthyma

SECONDARY INFECTIONS

• Impetigo often complicates both acute and chronic skin

diseases.

• Atopic dermatitis

• Psoriasis

• Herpes Simplex Virus

• Scabies

• Poison Ivy

• Pediculosis capitis

• Insect bites

IMPETIGO TREATMENT




Oral

Dicloxacillin 250 mg qid PO

Cephalexin 250 mg qid PO

Erythromycin 250 mg qid PO

Clindamycin 300-400 mg qid PO

Amoxicillin-clavulanate 875/125 mg bid PO

Topical

Retapmulin ointment Apply BID

Mupirocin 2% ointment Apply BID

PARONYCHIA

• Caused by breakdown in barrier between nail plate and adjacent nail fold from minor trauma to nail bed disrupts the fingertip’s natural barrier to outside pathogens inoculation of perionychium.

• Paronychia often related to:• onychophagia (ie, nail biting)

• finger sucking

• picking at a hangnail

• an ingrown nail

• manicures

• dishwashing,

• puncture-type trauma w/ or w/out a retained foreign body

• Noninfectious etiologies such as chemical irritants, excessive moisture, systemic conditions, and medications also can cause paronychia.

Shafritz A, Coppage J. Acute and chronic paronychia of the hand. J Am Acad Orthop Surg .2014 March;22(3):165-174.

ETIOLOGY OF PARONYCHIA

• Acute form: < 6 weeks duration

• MCC S. Aureus.

• Other causative organisms include γ-hemolytic strep, Eikenella corrodens,

group A b-hemolytic strep, and Klebsiella pneumoniae, Bacteroides,

Fusobacteria species, Enterococcus faecalis, Proteus species, and

Pseudomonas aeruginosa.

• Chronic: > 6 weeks duration.

• Usually caused by a fungal infection.

Shafritz A, Coppage J. Acute and chronic paronychia of the hand. J Am Acad Orthop Surg .2014 March;22(3):165-

174.

PARONYCHIA PRESENTATION

• Usually presents as localized pain, redness, inflammation, and edema of

lateral nail fold typically limited to a single digit often 2-5 days after initial

trauma.

• +/- Fluctuance of paronychium. Patients w/ delayed presentation may

develop fluctuance extending around nail, involving eponychium as

well as paronychium on both the radial and ulnar sides of the digit (ie,

runaround infection).

• +/- Purulence may develop underneath the nail plate, causing the nail

plate to pull away from sterile matrix.

Shafritz A, Coppage J. Acute and chronic paronychia of the hand. J Am Acad Orthop Surg .2014 March;22(3):165-

174.

Durdu M, Ruocco V. Clinical and cytologic features of antibiotic-resistant acute paronychia. J Am Acad Derm.

2014 Jan; 70(1)120-126.

ACUTE PARONYCHIA

Shafritz A, Coppage J. Acute and chronic paronychia of the hand. J Am Acad Orthop Surg. 2014 Mar;22(3):165-174.

Shafritz A, Coppage J. Acute and chronic paronychia of the hand. J Am Acad Orthop Surg. 2014 Mar;22(3):165-174.

PARONYCHIA TREATMENT

• The most common organism causing acute paronychia is S aureus,followed by S pyogenes, Pseudomonas pyocyanea, and Proteus vularis.

• Can be treated with warm water soaks 3-4 x per day (with or without povidone or chlorhexidine) and oral antibiotics.

• If an abscess is present, I&D is recommended in conjunction with oral antibiotics.

• Cephalexin, clindamycin, or amoxicillin plus clavulanate have a wide spectrum of activity against most pathogens isolated from paronychia.• In areas where local methicillin-resistant S aureus penetration is relatively high,

clindamycin remains a better option than amoxicillin plus clavulanate. • Oral trimethoprim-sulfamethoxazole can also be considered as a first-line agent.

• Removal of part of the nail plate may be required.

Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am. 2014 Aug;39(8):1628-33.

Ritting AW, O'Malley MP, Rodner CM. Acute paronychia. J Hand Surg Am. 2012 May;37(5):1068-70.

CELLULITIS

• Infection of deep dermis and subcutaneous tissue presenting as ill-

defined area with erythema, swelling, and tenderness. +/- fever,

chills

• Caused by disruption in skin barrier in immunocompetent patients

• Predisposing factors: previous attack of cellulitis, older age,

obesity, venous insufficiency, saphenous venectomy in CABG

patients, edema, and a skin surface disrupted by trauma,

ulceration, or inflammatory diseases of the skin, such as allergic

contact dermatitis, atopic dermatitis, and venous eczema

Gunderson CG. Cellulitis: Definition, Etiology, and Clinical Features. Am J Med. 2011, 124(12):1113-1122.

Hirschmann JV, Raugi GJ, Lower limb cellulitis and its mimics: Part I. Lower limb cellulitis, J Am Acad Dermatol. 2012

Aug;67(2):163.e1-163.e12.

CELLULITIS


Aug;67(2):163.e1-163.e12.

ETIOLOGY OF CELLULITIS

• MCC: group A strep (GAS), often residing in interdigital toe spaces;

less commonly S. Aureus.

• Purulent cellulitis usually caused by MRSA

• Erysipelas: specific type of cellulitis involving more super- ficial

dermal structures and distinguished clinically by raised borders and

clear demarcation between involved and uninvolved skin.

• Predominantly due to beta-hemolytic streptococci

• Infection with GAS causes antistreptolysin O (ASO), anti-

hyaluronidase, and anti-Dnase-B antibody positivity

• S. pyogenes erythrogenic exotoxins: SPE-A, SPE-B, SPE-C



Aug;67(2):163.e1-163.e12.

CELLULITIS MIMICKERS

• Infectious

• Necrotizing fasciitis

• Erysipelas

• Cutaneous abscess• Herpetic whitlow

• Erythema migrans

• Dermatologic

• Stasis dermatitis• Hypersensitivity reaction

• Fixed drug reaction

• Inflammatory

• Acute arthritis (gout)

• Acute bursitis

Can be difficult to diagnose….

**74% of in-patient dermatology consults for cellulitis were pseudocellulitis


Strazzula L, et al. Inpatient dermatology consultation aids diagnosis of cellulitis among hospitalized patients: A multi-

institutional analysis. J Am Acad Dermatol. 2015 Jul;73(1):70-5.

CELLULITIS TREATMENT

• Cultures of blood, cutaneous aspirates, biopsies, and swabs are not routinely recommended.

• Blood cultures however should be taken if systemic signs are presentor

• In patients with malignancy on chemotherapy, neutropenia, severe cell mediated immunodeficiency, immersion injuries, and animal bites.

• Typical cases of cellulitis should receive treatment against streptococci.Many clinicians also include coverage for MSSA.

• For coverage of streptococci and MRSA, use clindamycin or TMP-SMX w/ a B-lactam.





• When systemic signs of infection are present, inpatient treatment with

intravenous antibiotics are indicated.

• For patients whose cellulitis is associated with penetrating trauma,

MRSA infection elsewhere, IVDA, or SIRS, use vancomycin or another

antimicrobial effective against both MRSA and streptococci.

• In severely compromised patients broad-spectrum antimicrobial

coverage considered. Vancomycin plus either piperacillin-

tazobactam or imipenem/meropenem is recommended for severe

infections.

Stevens, D. “Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by

the Infectious Diseases Society of America”. Infectious Diseases Society of America. 9/1/2015.



• Necrotizing infections require emergent debridement with IV antibiotics.• The recommended duration of antimicrobial therapy is 5 days, but

treatment should be extended if the infection has not improved.• Hospitalize if: there is a concern for deeper or necrotizing infection, cases

of poor compliance, for those severely immunocompromised, or if outpatient treatment is failing.

• In lower extremity cellulitis, carefully examine the interdigital toe spaces because treating fissuring, scaling, or maceration may eradicate colonization with pathogens and reduce the incidence of recurrent infection.

• Prophylactic antibiotics, such as oral penicillin or erythromycin bid for 4-52 weeks, or IM benzathine penicillin every 2-4 weeks should be considered in those who have 3-4 episodes of cellulitis per year despite attempts to control predisposing factors.




ANTIBIOTIC RESISTANCE

• Antibiotics are among the most commonly prescribed drugs,

however, up to 50% of the time antibiotics are not optimally

prescribed, often done so when not needed, incorrect dosing or

duration. (CDC)

• Staphylococcus epidermidis (S. epidermidis) is completely resistant to

erythromycin and partially resistant to clindamycin and tetracycline

after 12 weeks of treatment.

• Evidence suggest the use of topical erythromycin and clindamycin – the most commonly used topical antibiotics in acne – has contributed to the gradual increase in resistance over the last 20 years. (Humphrey)

“Antibiotic/antimicrobial resistance, biggest threats.” Centers for Disease Control and Prevention. Last updated Aug.

26,2015. Last accessed Sep. 1,2015. http://www.cdc.gov/drugresistance/biggest_threats.html.

Singh S. Antibacterial Treatment for Uncomplicated Skin Infections. N Engl J Med. 2015Jun18;372(25):2459-60.

Humphrey S. Antibiotic resistance in acne treatment. Therapy Lett. 2012 Oct;17(9):1-3.


• Dermatologist prescribed 9.5 million antibiotic prescriptions in 2009

• Tetracyclines 69%

• Cephalophorins 11%

• TMP-SMX 7.5%

• Aminopenicillins 5.1%

• Macrolides 3.3%

Leyden JJ, Del Rosso JQ, Webster GF. Clinical considerations in the treatment of acne vulgaris and other

inflammatory skin disorders: focus on antibiotic resistance. Cutis 2007;79:9-25.


• Tetracycline-resistant and erythromycin or clindamycin-resistant strains

of P acnes were found in 20 and 50% of patients, respectively, in a

European study.

• Resistance has also been found in other pathogens commonly

associated with dermatology:

• Macrolide-resistant S. pyogenes and S. aureus

• Mupirocin-resistant S. aureus

• Vancomycin-resistant S. aureus

• Quinolone-resistant S. aureus, P. aeruginosa, and mycobacteria

Del Rosso JQ. A status report on the use of subantimicrobial-dose doxycycline: a review of the biologic and

antimicrobial effects of the tetracyclines. Cutis 2004;74:118-122.

Cooper AJ. Systematic review of Propionibacterium acnes resistance to systemic antibiotics. Med J Aust

1998;169:259-261.

Ross JI, Snelling AM, Carnegie E et al. Antibiotic-resistant acne: lessons from Europe. Br J Dermatol 2003;148:467-478.


• Sub-antimicrobial doses doxycycline (20 mg BID) compared with

antimicrobial doses (100 mg QD) in patients with moderate facial

acne, both treatments significantly decreased inflammatory

lesion counts

• 20 mg dose led to an 84% and 90% reduction in the number of papules and pustules, respectively.

• Sub-antimicrobial dosing should be considered when possible to

decrease the incidence of resistance and is being used in areas

of medicine other than dermatology.

Toossi P, Farshchian M, Malekzad F, Mohtasham N, Kimyai-Asadi A. Subantimicrobial-dose doxycycline in the

treatment of moderate facial acne. J Drugs Dermatol 2008;7:1149-1152.

Preshaw PM, Hefti AF, Jepsen S, Etienne D, Walker C, Bradshaw MH. Subantimicrobial dose doxycycline as adjunctive

treatment for periodontitis. A review. J Clin Periodontol 2004;31:697-707.

DERMATOLOGIC SURGERY AND WOUND INFECTIONS

• Post-surgical wound infections are the most common adverse

effect, but are not that common.

• In a large, multicenter, prospective study of Mohs procedures,

there were 83 (0.4%) reported infections out of 20, 821 cases.

• Similar low rates have been reported in smaller, multicenter

prospective studies (0.07-0.9%).

Alam M, Ibrahim O, Nodzenski M et al. Adverse events associated with mohs micrographic surgery: multicenter

prospective cohort study of 20,821 cases at 23 centers. JAMA Dermatol 2013;149:1378-1385.

Elliott TG, Thom GA, Litterick KA. Office based dermatological surgery and Mohs surgery: a prospective audit of

surgical procedures and complications in a procedural dermatology practice. Australas J Dermatol 2012;53:264-

271.

Merritt BG, Lee NY, Brodland DG, Zitelli JA, Cook J. The safety of Mohs surgery: a prospective multicenter cohort

study. J Am Acad Dermatol 2012;67:1302-1309.

PREVENTING SURGICAL SITE INFECTIONS

Antibiotic prophylaxis or not?• Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008

(JAAD) states antibiotics may be indicated for:• Procedures on the lower extremities or groin• Wedge excisions of the lip and ear• Skin flaps on the nose• Skin grafts• For patients with extensive inflammatory skin disease• For patients with high-risk cardiac conditions & a defined group of patients with prosthetic

joints when the procedure involves breach of the oral mucosa

• Recent survey study sent to Mohs surgeons concluded dermatologic surgeons overuse perioperative antibiotics for prevention of surgical site infection, infective endocarditis, and prosthetic joint infection based on current recommendations.

Wright TI, Baddour LM, Berbari EF et al. Antibiotic prophylaxis in dermatologic surgery: advisory statement 2008. J Am

Acad Dermatol 2008;59:464-473

Bae-Harboe YS, Liang CA. Perioperative antibiotic use of dermatologic surgeons in 2012. Dermatol Surg 2013;39:1592-

1601.

PREVENTING SURGICAL SITE INFECTIONS

Prepping of the skin• A 2015 Cochrane review of current evidence found some evidence

that preoperative skin preparation with 0.5% chlorhexidine in methylated spirits was associated with lower rates of surgical site infections following clean surgery than alcohol-based povidone iodine paint, however this data was from a poor single study.

• A similar review of literature found that while there are few well-controlled studies demonstrating superiority of a given regimen, alcohol-based iodophor and chlorhexidine products seem to exhibit greater efficacy than their aqueous counterparts.

• Both concluded ultimately it is up to the surgeon to choose and that future studies are needed.

Dumville JC, McFarlane E, Edwards P, Lipp A, Holmes A, Liu Z. Preoperative skin antiseptics for preventing surgical wound

infections after clean surgery. Cochrane Database Syst Rev 2015;4:CD003949.

Echols K, Graves M, LeBlanc KG, Marzolf S, Yount A. Role of antiseptics in the prevention of surgical site infections.

Dermatol Surg 2015;41:667-676.

PREVENTING SURGICAL WOUND INFECTIONS

How sterile do we need to be?

• In a prospective comparison study of 1,255 Mohs cases, infection risk was the same between high-cost (n = 5, 0.9%) and low-cost groups (n = 5, 0.7%).• High cost=

• Sterile gloves for all stages & closure

• Sterile half-drape for closure

• Sterile knee length gown for closure

• Low cost=• Sterile gloves for closure only

• Concluded that It may be possible to further reduce costs without altering infection rate by using clean, nonsterile gloves during reconstruction as well.

Lilly E, Schmults CD. A comparison of high- and low-cost infection-control practices in dermatologic surgery.

Arch Dermatol 2012;148:859-861.


Sterile gloves vs non-sterile gloves

• In 2,025 Mohs cases, there was no increase in prevalence of

infection using sterile glove for both excision and reconstruction

(0.5%) compared to the using non-sterile gloves (0.49%)

• The cost of gloves was $5.66 for 1 sterile glove case and $1.63

for 1 non-sterile case

• Similar results were seen in previous smaller studies

Mehta D, Chambers N, Adams B, Gloster H. Comparison of the prevalence of surgical site infection with use of sterile

versus nonsterile gloves for resection and reconstruction during Mohs surgery. Dermatol Surg 2014;40:234-239.

Xia Y, Cho S, Greenway HT, Zelac DE, Kelley B. Infection rates of wound repairs during Mohs micrographic surgery

using sterile versus nonsterile gloves: a prospective randomized pilot study. Dermatol Surg 2011;37:651-656.

Rhinehart MB, Murphy MM, Farley MF, Albertini JG. Sterile versus nonsterile gloves during Mohs micrographic surgery:

infection rate is not affected. Dermatol Surg 2006;32:170-176.


Topical antibiotics vs petrolatum/paraffin

• In a recent systematic review and meta-analysis, there was no

statistically significant difference in incidence of postsurgical

wound infections between the use of topical antibiotics and

petrolatum/paraffin.

• There was also no significant difference between applying and

not applying ointment to surgical wounds.

• Wounds at increased risk of developing surgical site infections• wounds in diabetics• wounds located in certain anatomic regions• wounds created by some surgical procedures

Saco M, Howe N, Nathoo R, Cherpelis B. Topical antibiotic prophylaxis for prevention of surgical wound

infections from dermatologic procedures: a systematic review and meta-analysis. J Dermatolog Treat

2015;26:151-158.

COSMETIC PROCEDURES AND INFECTIONS

Dermal Fillers

• According to a recent JAAD CME article, infections associated with

cosmetic procedures are rare

• 0.2% infections with soft tissue filler injections

• 4 cases of cellulitis with calcium hydroxylapatite filler out of 2,089 soft filler injections

• Rare infections can occur:

• 3 cases of mycobacterium chelonae from one plastic surgery clinic

• Source was tap water from clinic pts used nonsterile ice pre-procedure

Lolis M, Dunbar SW, Goldberg DJ, Hansen TJ, MacFarlane DF. Patient safety in procedural dermatology: Part II. Safety

related to cosmetic procedures. J Am Acad Dermatol 2015;73:15-24.

Daines SM, Williams EF. Complications associated with injectable soft-tissue fillers: a 5-year retrospective review. JAMA

Facial Plast Surg 2013;15:226-231.

Rodriguez JM, Xie YL, Winthrop KL et al. Mycobacterium chelonae facial infections following injection of dermal filler.

Aesthet Surg J 2013;33:265-269

COSMETIC PROCEDURES AND INFECTIONS

Lasers• Reported bacterial infection

rates post-CO2 procedures range from 2.2%-8.2%, with some evidence that antibiotic prophylaxis may decrease infection rates.

• Rare infections have been reported:• M. chelonae skin infection has been

associated with ablative laser procedures such as CO2 and fractional CO2 laser resurfacing.

• M. chelonae skin infection developed 1 week after a hair removal session with variable-pulsed alexandrite laser performed on both legs at a beauty center.

Uslan DZ, et al. Skin and soft tissue infections due to rapidly growing mycobacteria: comparison of clinical features,

treatment, and susceptibility. Arch Dermatol 2006;142:1287-1292.

Culton DA, et al. Nontuberculous mycobacterial infection after fractionated CO(2) laser resurfacing. Emerg Infect Dis

2013;19:365-370.

Palm MD, et al. Mycobacterium chelonae infection after fractionated carbon dioxide facial resurfacing (presenting as

an atypical acneiform eruption): case report and literature review. Dermatol Surg 2010;36:1473-1481.

Shamsaldeen O, et al. The adverse events of deep fractional CO(2): a retrospective study of 490 treatments in 374

patients. Lasers Surg Med 2011;43:453-456.

Manuskiatti W, et al. Prophylactic antibiotics in patients undergoing laser resurfacing of the skin. J Am Acad Dermatol

1999;40:77-84.

REFERENCES

• Zabielinski M, McLeod M, Aber C, Izakovic J, Schachner L. Trends and antibiotic susceptibility patterns of

methicillin-resistant and methicillin-sensitive Staphylococcus aureus in an outpatient dermatology facility. JAMA

Dermatol. April 2013;149(4):427-432. D.M.

• Elston. Community-acquired methicillin-resistant Staphylococcus aureus. J Am Acad Dermatol, 56 (2007), pp. 1–

16.

• Kirkland EB, Adams BB. Methicillin-resistant Staphylococcus aureus and athletes. J Am Acad Dermatol. 2008

Sep;59(3):494-502.

• Lloyd KM, Schammel L. Clinical Progression of CA-MRSA Skin and Soft Tissue Infections: A New Look at an


• Bangert S, Levy M, Hebert A A. Bacterial Resistance and Impetigo Treatment Trends: A Review. Pediatr

Dermatol. 2012;29: 243–248.

• Moran GJ, Abrahamian FM, LoVecchio F, Talan DA. Acute Bacterial Skin Infections: Developments Since the

2005 Infectious Diseases Society of America (IDSA) Guidelines. J Emerg Med. 2013 Jun;44(6)e397-e412.

• Shafritz A, Coppage J. Acute and chronic paronychia of the hand. J Am Acad Orthop Surg. 2014

Mar;22(3):165-174.

• Durdu M, Ruocco V. Clinical and cytologic features of antibiotic-resistant acute paronychia. J Am Acad Derm.

2014 Jan; 70(1)120-126.

• Gunderson CG. Cellulitis: Definition, Etiology, and Clinical Features. Am J Med. 2011, 124(12):1113-1122.

REFERENCES

• Stevens, D. “Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014

Update by the Infectious Diseases Society of America”. Infectious Diseases Society of America. Accessed

9/1/2015. http://www.idsociety.org/Organ_System/#Skin%20&%20Soft%20Tissue

• Hirschmann JV, Raugi GJ, Lower limb cellulitis and its mimics: Part I. Lower limb cellulitis, J Am Acad

Dermatol. 2012 Aug;67(2):163.e1-163.e12.

• Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am. 2014 Aug;39(8):1628-33.

• Ritting AW, O'Malley MP, Rodner CM. Acute paronychia. J Hand Surg Am. 2012 May;37(5):1068-70.

• Wright TI, Baddour LM, Berbari EF et al. Antibiotic prophylaxis in dermatologic surgery: advisory statement

2008. J Am Acad Dermatol 2008;59:464-473.

• Bae-Harboe YS, Liang CA. Perioperative antibiotic use of dermatologic surgeons in 2012. Dermatol Surg

2013;39:1592-1601.

• Saco M, Howe N, Nathoo R, Cherpelis B. Topical antibiotic prophylaxis for prevention of surgical wound

infections from dermatologic procedures: a systematic review and meta-analysis. J Dermatolog Treat

2015;26:151-158.

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