Inpatient Skin and Soft Tissue Infections

Keri Holmes-Maybank, MDMedical University of South CarolinaSeptember, 2012

Identify appropriate empiric antibiotics for treatment of SSTI’s.

Identify appropriate antibiotics for deescalation of SSTI treatment.

Recognize patients appropriate for inpatient hospitalization of SSTI’s.

Recognize appropriate use of blood cultures, needle aspiration and punch biopsies in SSTI’s.

Objectives

Blood culture for skin and soft tissue infections are extremely low yield, approximately 5%.

Consider hospitalization for patients with systemic signs of illness.

MRSA infections have led to an increase in skin and soft tissue infections.

Using guidelines for skin and soft tissue infections leads to a decrease in the emergence of antibiotic resistance.

Key Messages

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

SSTI’s

“Practice guidelines are systematically developed statements to assist practitioners and patients in making decisions about appropriate health care for specific clinical circumstances.”

IDSA Guidelines

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◦ No change in adverse outcomes◦ Decreased costs

Guidelines

Systemic illness

◦ HR >100 and◦ Temp >38oC or <36oC and◦ Systolic bp <90 or decrease of 20 mmHg <

baseline Hypotension and

◦ CRP>13◦ Marked left shift ◦ Elevated creatinine◦ Low serum bicarbonate◦ CPK 2 x the upper limit of normal

Inpatient Hospitalization

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

Inpatient Hospitalization

Immune status Geographic locale Travel history Recent trauma or surgery Previous antimicrobial therapy Lifestyle - occupation Hobbies Animal exposure Bite exposure

Obtain Careful History

Blood cultures positive <5% Needle aspiration 5-40% Punch biopsy 20-30%

Testing

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

Blood Cultures

HR >100 , Temp >38oC and <36oC, Sys<90mmHg

Hypotension and ◦ 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

Needle Aspiration or Skin Biopsy

Indicators of more severe disease:◦ Low sodium◦ Low bicarb◦ High creatinine◦ New anemia◦ Low or high wbc◦ High CRP (associated with longer hospitalization)

SSTI

Recent hospitalization Residence in long term care facility Recent antibiotic treatment HIV Men who have sex with men Injection drug use Hemodialysis Incarceration Military service Sharing needles, razors, sports equipment Diabetes

Empiric Anti-MRSA Antibiotics

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

Deescalation

If no improvement in systemic signs in 48 hours

If no improvement in skin in 72 hours As antibiotics kill organisms, toxins released

may cause a worsening of skin findings in first 48 hours

Broaden Antibiotics

65% relative increase since 1999 600,000 admissions annually

Cellulitis

Obesity Edema

◦ Venous insufficiency ◦ Lymphatic obstruction

Fissured toe webs ◦ 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

Risk Factors for Cellulitis

Saphenous venectomy Axillary node dissection for breast cancer Gyn malignancy surgery with lymph node

dissection *** in conjuction with XRT Liposuction

Surgical Risk Factors

No purulent drainage, no exudate, no associated abscess

beta hemolytic streptococci

Antibiotics:◦ Nafcillin ◦ Cefazolin ◦ Ceftriaxone ◦ Clindamycin ◦ Vancomycin

Modify to MRSA coverage if ◦ No improvement in skin findings within 72 hours◦ Signs of severe systemic illness

Non-Purulent Cellulitis

Deescalation: ◦  Penicillin◦ Amoxicillin ◦ Amoxicillin/clavulanate ◦ Cephalexin

Treatment duration: ◦ Discontinue abx 3 days after acute inflammation

disappears◦ Usually 5-10 days of treatment

Non-Purulent Cellulitis

Purulent drainage Exudate Absence of a drainable abscess Deeper tissue - surgical/traumatic wound

infection, major abscess, infected ulcer or burn

Purulent/Complicated Cellulitis

MRSA coverage Antibiotics:

◦ Vancomycin◦ Clindamycin◦ Linezolid (restricted to ID) ◦ Daptomycin (restricted to ID)

Purulent/Complicated Cellulitis

Deescalation: ◦ Clindamycin◦ Trimethoprim/sulfamethoxazole◦ Linezolid (restricted to ID)

Treatment duration: ◦ Discontinue abx 3 days after acute inflammation

disappears◦ Usually 5-10 days of treatment

Purulent/Complicated Cellulitis

Elevation of affected leg Compression stockings Treat underlying tinea pedis, eczema,

trauma Keep skin well hydrated

Secondary Treatment of Cellulitis

Acute dermatitis Gout Herpes zoster Lipodermatosclerosis Deep vein thrombosis Contact dermatitis Drug reaction Foreign body reaction Herpes zoster

Confused with Cellulitis

Abscess

ALWAYS, ALWAYS ◦Incision and drainage ◦Culture aspirate

Abscess

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

Abscess –When to Add Antibiotics

MRSA coverage:cellulitis, severe disease, rapid progression, septic phlebitis, constitutional symptoms, difficult to drain

Antibiotics:◦ Vancomycin ◦ Clindamycin ◦ Daptomycin (restricted to ID)◦ Linezolid (restricted to ID)

c-MRSA or beta hemolytic streptococci Antibiotics

◦ Clindamycin◦ Trimethoprim/sulfamethoxazole + beta lactam◦ Doxycycline + beta lactam

Abscess Antibiotic Coverage

Deescalation: ◦ Clindamycin◦ Trimethoprim/sulfamethoxazole◦ Linezolid (restricted to ID)

Treatment duration:◦ Discontinue abx 3 days after acute inflammation

disappears◦ Usually 5-10 days of treatment

Abscess

Animal Bites

Pasteurella – mc organism

Antibiotics:◦ Ampicillin/sulbactam◦ Piperacillin/tazobactan◦ Cefoxitin◦ Meropenem ◦ Ertapenem (restricted to ID and Surgery)

Tetanus toxoid (if not up to date)

Animal Bites

Deescalation ◦ Amoxicillin/clavulanate ◦ Doxycycline

Treatment duration:◦ Discontinue abx 3 days after acute inflammation

disappears ◦ Usually 5-10 days of treatment

Animal Bites

Human Bites

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***

Human Bite

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

Human Bites

Surgical Site Infection

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

Surgical Site Infection

If temperature >38.5oC or HR >100 bpm: Trunk, head, neck, extremity

◦ Cefazolin◦ Clindamycin◦ Vancomycin if MRSA is suspected

Perineum, gi tract, female gu tract ◦ Cefotetan◦ Ampicillin/sulbactam◦ Ceftriaxone + metronidazole or clindamycin◦ Fluoroquinolone + clindamycin

Treatment duration:◦ Usually 24-48 hours or for 3 days after acute inflammation

resolves

Surgical Site Infection

Neutropenia and SSTI’s

ALWAYS blood CULTURES Initial infection - <7 days neutropenia

Antibiotics◦ Carbapenems◦ Cefepime◦ Ceftazidine◦ Piperacillin/tazobactam

PLUS ◦ Vancomycin◦ Linezolid (restricted to ID)◦ Daptomycin (restricted to ID) ◦ (discontinue if culture negative after 72-96 hours)  

Neutropenic Patients with SSTI

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

PLUS ◦ Vancomycin◦ Linezolid (restricted to ID)◦ Daptomycin (restricted to ID) ◦ (discontinue if culture negative after 72-96 hours)

Neutropenic Patients with SSTI

Deescalation: ◦ Ciprofloxacin and amoxicillin/clavulanate

Treatment duration:◦ At least 7 days

Neutropenic Patients with SSTI

Device predisposes to SSTI 66% Gram positive

Entry site infection◦ Antibiotics

Tunnel infection and vascular port-pocket infection◦ Device removal and antibiotics

Vascular-Access Devices in Neutropenia

Diabetic Foot Ulcers

Not all diabetic foot ulcers are infected.

Indications of infection:◦ Purulent secretions OR ◦ 2 of manifestations of inflammation:

Redness Warmth Swelling/induration Pain/tenderness

Infected Diabetic Foot Ulcers

Common, complex, costly Largest number of diabetes related hospital

bed days Most common proximate, non-traumatic

cause of amputations

Diabetic Foot Ulcers

Always obtain specimen (biopsy, ulcer curettage, aspiration) and treat with antibiotics and wound care

  Mild ulcer

◦ Cellulitis or erythema extends <2cm around ulcer, infection limited to skin

Antibiotics:◦ Clindamycin◦ Cephalexin◦ Amoxicillin/clavulanate◦ Trimethoprim/sulfamethoxazole

Treatment duration◦ Usually 1-2 weeks treatment

Diabetic Foot Ulcers

Moderate or Severe ulcer ◦ Cellulitis or erythema extends >2cm around ulcer, fever, ams,

hypotension, leukocytosis, acidosis, severe hyperglycemia

Antibiotics:◦ Vancomycin and ceftazidime ◦ (consider adding metronidazole, piperacillin/tazobactam, meropenem)

Deescalation:◦ Moxifloxacin◦ Amoxicillin/clavulanate◦ Trimethoprim/sulfamethoxazole

Treatment duration:◦ Usually 2-4 weeks of treatment

Diabetic Foot Ulcers

Wound care Debridement Glycemic control Evaluate vascular status

Secondary Treatment of Diabetic Foot Ulcers

Gunderson CG. Cellulitis: Definition, etiology, and clinical features. Am J Med2011;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 Societ

y of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis 2011;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.

References